The Obstetrics and Gynecology Hospitalist: Risk Management Implications.

The concept of a 24/7 in-house obstetrician, serving as an obstetrics and gynecology (Ob/Gyn) hospitalist, provides a safety-net for obstetric and gynecologic events that may need immediate intervention for a successful outcome. The addition of an Ob/Gyn hospitalist role in the perinatal department mitigates loss prevention, a key precept of risk management. Inherent in the role of the Ob/Gyn hospitalist are the important patient safety and risk management principles of layers of back-up, enhanced teamwork and communications, and immediate availability.

The "6 A's": A risk manager's guide to emergency cesarean delivery.

The allegation of delay in performing an emergency cesarean delivery is common in litigation involving neurological injury to newborns. Analyzing the actual performance of an emergency cesarean involves multiple steps, individuals, and systemic processes that need coordination for appropriate action when necessary. This article gives risk managers a systematic way to evaluate a given perinatal unit's approach to the ability to perform an emergency cesarean through evaluating the 6 "A"s: Assess, Alert, Align, Assemble, Act, and Analyze. Each of these elements is discussed based on current evidence. A checklist that may be useful in the evaluation of the elements of performance of emergency cesarean delivery is provided.

Are unintentional nurse-attended deliveries a patient safety issue?

Unintentional nurse-attended deliveries occur on most labor and delivery units. Some precipitous deliveries are unavoidable, but others, occurring after admission with the expectation that the woman's designated provider would attend the delivery are, for a variety of reasons, still attended only by nursing staff. This study was undertaken to establish a benchmark for unintentional nurse-attended deliveries. Fifty perinatal units were studied with respect to their statistics regarding unintentional nurse-attended deliveries. Ten of the 50 perinatal units (20%) did not keep statistics on unintentional nurse-attended deliveries. The average percentage of unintentional nurse-attended deliveries in the 40 perinatal units that did keep this statistic was 1.38% (range 0-5.3%). This benchmark should be useful as the safety issues for these types of deliveries are analyzed. Audits regarding timing of examinations during labor, practices regarding notification of providers and other communication practices, provider arrival times, and involved personnel should help perinatal units develop policies, protocols, and strategies to minimize the chances for unintentional nurse-attended deliveries when there should be enough time and appropriate communication to allow the woman's provider to be present at the delivery.

Obstetrics Hospitalists: Risk Management Implications.

The concept of having an in-house obstetrician (serving as an obstetrics [OB] hospitalist) available 24 hours a day, 7 days a week provides a safety net for OB events that many need immediate intervention for a successful outcome. A key precept of risk management, that of loss prevention, fits perfectly with the addition of an OB hospitalist role in the perinatal department. Inherent in the role of OB hospitalists are the patient safety and risk management principles of improved communication, enhanced readiness, and immediate availability.

Vacuum-assisted vaginal delivery (VAVD)-basics for the risk manager.

The neonatal intensive care unit (NICU) manager calls you about a baby delivered last night now with brain trauma. She understands that it was a difficult delivery with a vacuum. There were "multiple pop-offs" and, after the baby was delivered, the NICU resuscitation team was called. The Apgar scores were 3 and 5. They are requesting risk management to lead a debriefing today. What to ask? How many pop-offs are allowed? What was the interaction between the nurses and physician? Why wasn't the resuscitation team in attendance before the delivery? Was the vacuum placed properly? How many pulls? How long was the vacuum in place? What should be documented, and was the documentation adequate? All of these are appropriate questions for an adequate analysis of an adverse outcome resulting from a vacuum-assisted vaginal delivery (VAVD). This article focuses on the risk management issues of VAVD in order to give the risk manager a better understanding of appropriate use, data-gathering tools, educational opportunities, and assistance in establishing a culture of safety for the entire perinatal team regarding the use of the vacuum device.

Safety and underwater birth-what every risk manager should know.

Underwater birthing has become a popular birth practice in some areas of the country. Although many of these deliveries occur in a home birth setting, the practice has also been implemented in hospitals and birthing centers. There is continued controversy about the risks and benefits of underwater birthing (as opposed to hydrotherapy during labor), and many risk managers are unaware of these potential risks and benefits. The purpose of this article is to review the significant risks and benefits of underwater birthing, to review relevant literature and several Professional Organizations' Position Statements regarding underwater birthing, and to provide a safety checklist for hospital risk managers who wish to consider adding underwater birthing to their current scope of perinatal care.

The OB hospitalist and the risk manager: ready for prime time.

In 1996, Wachter and Goldman described a new model of care in which hospital-based physicians provided patients' inpatient care in lieu of the patient's primary physician.(1) They termed these physicians hospitalists. The hospitalist movement had taken hold, and by 1999, 65% of internists had hospitalists in their community and 28% reported using them for inpatient care.(2) In 2003, Louis Weinstein, in an article entitled "The Laborist: A New Focus of Practice for the Obstetrician"(3) advocated for the adoption of the hospitalist model to obstetrical care. In a 2010 study, of 28,545 members of the American College of Obstetricians and Gynecologists (ACOG) contacted in a national survey, 7,044 clinicians responded, which yielded a response rate of 25%. Of the respondents, 1,020 clinicians (15% of respondents, 3.6% of the entire sample) described themselves as obstetrics/gynecology hospitalists or laborists.(4) According to the web site www.obgynhospitalist.com, there are at least 115 hospitals in the country that utilize a laborist or OB hospitalist model of care.(5).

P.U.R.E. (purposeful, unambiguous, respectful, and effective) Conversations and electronic fetal monitoring: gaining consensus and collaboration.

A revised nomenclature regarding electronic fetal heart rate monitoring was accepted at a National Institute of Child Health and Human Development consensus conference in 2008. At the heart of patient safety are communication strategies that enhance teamwork and collaboration between health care professionals. Communications is a complex 2-way process that involves more than transfer of factual information. P.U.R.E. (purposeful, unambiguous, respectful, and effective) Conversations in Obstetrics is an acronym that helps facilitate this communication process in perinatal care. P.U.R.E. stands for purposeful, unambiguous, respectful, and effective. The P.U.R.E. Conversations approach involves refinement of the mental processes associated with delivering the message, delivery of the message with data, accuracy, and direct requests for action, attention to relationships and behaviors between the communicating parties, and real-time assessment of the effectiveness of the communication. When the new electronic monitoring nomenclature is combined with an effective communication tool, one could expect to see a reduction in communication failures that could lead to adverse perinatal outcomes.

Vaginal birth after cesarean checklist: an evidence-based approach to improving care during VBAC trials.

Several medical organizations and specialty societies, as part of their approach to patient safety, have recommended that checklists be introduced and followed in certain high-risk healthcare situations. There is now evidence that following these kinds of checklists leads to improved outcomes. This article recommends a checklist that can be completed for each patient when she is admitted for a trial of labor after a previous cesarean delivery (VBAC). The elements of the checklist will help confirm the preparedness of the organization, compliance with national standards, and the consent of the patient for the VBAC trial.

Standardizing criteria for scheduling elective labor inductions.

Induction of labor has become routine practice in perinatal units across the United States, with rates reaching a high of 21.2% of births in 2003-2004. This article describes the process our institution used to standardize the criteria for scheduling inductions. Specifically, we aimed to increase the consistency in practice for scheduling and performing elective inductions, including mandating gestational age of 39 completed weeks, ensuring cervical ripeness, and disallowing the use of cervical ripening agents. The nurses' participation, from planning to implementation, was critical in the success of this evidence-based practice change.