Reducing litigation risks related to Obstetrics and Nursing:

Increasing demands society has placed on obstetric nursing, especially through issues of malpractice, has put our nation’s pregnant mothers at risk for a national crisis due to a lack of care to meet the demands of childbirth. Ultimately, OB nurses need to decrease the risk factors that are increasing malpractice claims.
Some nursing strategies that will help to do this include preventative measures within the workplace to minimize errors in patient care; insisting that there be a designated support person in every woman’s laboring process; and implementing some of the strategies of care in midwifery because midwives have been found to have better outcomes in delivery even with the inclusion of “risky” patients.

In numerous counties across the nation pregnant mothers must drive anywhere from 45 to 80 miles for prenatal care (Moninger, 2007). The doctors can no longer afford to deliver babies; they are being charged malpractice insurance premiums into the six figures. Many maternity wards have closed across the nation due to a lack of obstetricians; this even affects the midwives in those areas considering they often have to work in collaboration with obstetricians (Moninger, 2007). Liability insurance for certified nurse midwives has increased as well. Neonatal/obstetric nursing can often be at the forefront of a malpractice suit when an injury to a neonate happens in the hospital’s care (Verklan, 2004). The author, Verklan (2004), goes on to give an example of a perinatal nurse who questioned a physician’s orders in the care of an induced mother, the nurse followed all orders regardless of her questions and the child ended up with severe retardation. Here, the doctor misinterpreted the electronic fetal monitor, and ordered the continuation of Oxytocin. The nurse’s questionable administration of Oxytocin is what placed her at fault and in the courtroom. According to the authors the misinterpretation of the electronic fetal monitor often leads to suit. Another major factor that comes into play in medical malpractice hearings is insufficient documentation (Greenwald & Mondor, 2003). With all of the possibilities for malpractice suit in the obstetric setting, a plan to reduce errors and increase positive outcomes is the only option for obstetric nurses.
OB nurses must decrease risk factors in labor and deliver through a prophylactic approach, starting with transitioning teamwork innovation from other industries into healthcare, resulting in better safety. Implementation of the MedTeams Training Program to enhance overall performance on the Labor & Delivery floor it is a strategy that could decrease the risk of error and the inevitable litigation that accompanies malpractice (Harris, et al, 2006). MedTeams Training is something the registered nurse will have to justify to hospitals management. It addresses management of distractions, changing coping mechanisms, behaviors, and attitudes; improving communication and teamwork; and evaluation of information related to operational dangers. “In a closed case review of civilian emergency department risk management cases, Dynamics Research Corporation suggested that 43% of errors were due to a lack of team behaviors (Harris, et al, 2006).” A retrospect review of closed claim L&D files by two separate pairs of physician-nurse experts suggested that 40% or more of L&D malpractice events could have been prevented by a formal team approach (Harris et al, 2006).
A lack of adequate teamwork between obstetrical nurses is as big a problem as a lack of physical or emotional support for the patient. Having a support person during labor and childbirth has been associated with decreased rates of cesarean births and lengthy labor (Cragin, & Kennedy, 2006). Therefore, suggesting that patients choose a person to be their birth partner as added support through the four stages of the laboring process will lessen the complications that often are associated with malpractice cases. Added support provides a positive presence to the situation which potentially can improve the patients’ labor and delivery.
Certified Nurse Midwives have been found to have better outcomes in delivery even with the inclusion of “risky” patients. According to a study done to examine optimality in women at equally moderate risk, “those cared for by midwives achieved a higher optimality score (less use of technology and equal or better health outcomes) than those cared for by physicians, with equally positive neonatal outcomes (Cragin & Kennedy, 2006).” This would be a wonderful research opportunity for the Registered Labor and Delivery nurse. If implementing some of the strategies of the CNM in hospital care will decrease adverse outcomes in the hospital setting than in turn malpractice litigation will also be decreased. Collaboration between CNM and OB RN will also decrease the stress that the patient feels just by being in the hospital.
Increased adverse outcomes in obstetric nursing have led to increases in malpractice cases, and therefore a lack of care due to doctors and nurse midwives leaving practice. With the demands society has placed on obstetric nursing, especially through issues of litigation, our nation’s pregnant mothers are at risk for a national crisis of not being able to meet the demands of childbirth. Ultimately, OB nurses need to decrease the risk factors that are increasing malpractice claims. In order to do this first RNs will implement team strategies and coordination, which in turn will reduce risk through a decreased work load and open communication. Next, the RNs will suggest a system that designates a person of support to help ob patients through their labor; this will decrease mom’s anxiety resulting in fewer complications during birth. The last strategy the RN will do is through taking on some of the qualities of care that nurse midwives are using, as in less technology, which will also lead to better outcomes for mom’s meaning better outcomes for babies.
A. Intervention 1: implementing some of the strategies of care in midwifery.
i. Disadvantage 1: Knowledge deficit related to midwifery.
Midwifery has been proven to be as effective as or even more effective than hospitals with good outcomes related to childbirth. Yet, the findings are not being recognized by hospitals nor insurance companies making it very hard for certified midwives to practice and for patients to find coverage if they decide to go with a midwife rather than an obstetrician. “Many insurers discourage giving birth at home, a practice usually attended by a midwife, arguing that it is not as safe as going to a hospital” (Perez-pena 2004). For example, “Aetna (a health insurance company) will not contract with some birthing centers because it considers them inadequate for emergencies or too far from hospitals, and it will not cover any home births unless required to by state law . . . Midwives argue that they actually save health insurers money, because their care results in fewer Caesareans and other expensive procedures” (Perez-pena 2004). Without the practice of midwifery taken seriously hospitals and insurance companies continue to utilize too many machines, too many drugs, and end up causing more problems using this whole medicalized, institutionalized way of birth that doctors do (Perez-pena 2004).
ii. Disadvantage 2: Lack of insurance related to midwifery practice.
Patients across the nation are turning to midwifery for childbirth practices often being stopped in their tracks by the insurance companies denying coverage. On another note midwives across the nation are being stopped in their tracks by increased malpractice insurance rates and decreased Medicare coverage sending them out of business. “Certified Nurse Midwives receive only 65% of the physician reimbursement rate for comparable services” (Health Insurance Week 2005). Many patients are being forced to pay larger shares of their bills with a CNM than if they would’ve gone to a doctor (Perez-pena 2004). The obstacles of both patient and midwife in regards to insurance have driven many birthing centers out of business. “The Elizabeth Seton Childbearing Center in Greenwich Village, shut it’s doors, driven out of business by rising medical malpractice insurance premiums . . . when Seton needed a new malpractice policy last summer, the best quote it could find was a 400% premium increase” (Perez-pena 2004). “ Midwives face fast-rising malpractice insurance premiums, and new limitations imposed on their practices by many hospitals and health insurance companies” (Perez-pena 2004).
B. Intervention 2: Transitioning teamwork innovation from other industries into healthcare.
i. Disadvantage 1: Knowledge deficit related to strategies for teamwork.
Strategies for teamwork innovation are not being looked at seriously. Hospitals are not realizing the benefits of spending money on such quality assurance programs to decrease the risk of malpractice and lower malpractice rates in the long run. “The MedTeams training program, a nationally funded research project, provided the framework for team training in several labor and delivery units in the United States. Many challenges were confronted when team training was implemented” (Harris; et al 2006). The article goes on the state, “little has been written about how to implement teamwork initiatives to ensure success” (Harris, et al 2006). However, formal teamwork training was almost nonexistent in obstetric care settings until the development of the MedTeams training program leaders (managers, directors, clinical nurse specialists, chiefs of obstetrics and anesthesiology) attended several days of training. Staff did not attend. As a result, they perceived that their input did not matter and that the project was simply another change they did not control (Harris, et al 2006). Therefore, the MedTeams training program dedicated to providing a framework for team training in labor and delivery units confronted many challenges.
ii. Disadvantage 2: Malpractice insurance rates shut down OB units.
Malpractice rates are launching our country into national crisis due to a lack of childbirth care. There are numerous OB units and birthing centers that have already been shut down without ever giving teamwork innovation a chance. Teamwork innovation programs, such as Medteams Training or other quality assurance programs are not being implemented prior to shut down, and the power that they hold in decreasing risk will never be known in those locations. “Jeanes Hospital in Philadelphia closed its obstetrics ward in May, it became the 33rd Pennsylvania hospital, and the 14th in the Philadelphia area, to stop delivering babies in the last decade” (Thrall 2007). Only one hospital in Rhode Island has taken steps to prevent this trend, the hospital, with a captive insurance plan, offers discounts of up to 30% for doctors who participate in quality assurance training (Thrall 2007).
References New Stuff:
1. Bush, H. (2007). Perfect storm forces hospitals to shut down obstetrics services. Hospitals & Health Networks, 81(9), 20.
2. Harris, K. T., Treanor, C. M., & Salisbury, M. L. (2006). Improving patient safety with team coordination: challenges and strategies of implementation. Journal of Obstetrics and Gynecology Neonatal Nursing, 35(4), 557-566.
3. Health Insurance Week (2005). Obstetrics; Midwives to lobby U.S. congress for Medicare reimbursement equity. http://proquest.umi.com/pdqweb?did=860911461&Fmt=3&clientid=3236&RQT=309&VName=PQD
4. Perez-pena, R. (2004). Use of midwives, a childbirth phenomenon, fades in city. New York Times, B.1.
Reference List Original:

1. Cragin, L., & Kennedy, H. P. (2006). Linking obstetric and midwifery practice with optimal outcomes. Journal of Obstetrics and Gynecology Neonatal Nursing, 35(6), 779-785.

2. Greenwald, L. M., & Mondor, M. (2003). Malpractice and the perinatal nurse. Journal of Perinatal & Neonatal Nursing, 17, 101-109. Retrieved January 7, 2007, from Proquest online database.

3. Harris, K. T., Treanor, C. M., & Salisbury, M. L. (2006). Improving patient safety with team coordination: challenges and strategies of implementation. Journal of Obstetrics and Gynecology Neonatal Nursing, 35(4), 557-566.

4. Moninger, J. (2007, January). The doctor drought: skyrocketing insurance premiums are forcing thousands of ob-gyns out of the baby business. And your doctor could be the next to go. Parents, 62-65, 116-117.

5. Verklan, M. T. (2004). Malpractice and the neonatal intensive-care nurse. Journal of Obstetrics and Gynecology Neonatal Nursing, 33(1), 116-123.