Ethics and Medico-legal implications in delivery room emergencies.

There is very little law-either case law or statutory law - that regulates delivery room decisions about resuscitation of critically ill newborns. Most of the case law that exists is decades old. Thus, physicians cannot look to the law for much guidance about what is permissible or prohibited. Local hospital policies and professional society statements provide some guidance, but they cannot be all-inclusive and encompass all potentially encountered scenarios. Ultimately, the physician, the medical team, and the parents must try to reach a shared decision about the best course of action for each individual infant and each unique family. In this paper, we review some of the case law that may be applicable to such decisions and make recommendations about how decisions should be made.

Facility Design: Reimagining Approaches to Childbirth in Hospital and Birth Center Settings.

Few maternity care clinicians are aware of the current regulations that guide design standards for childbirth facilities in the United States or the regulatory history. There is considerable variance among state regulations as well as oversight of facility standards for healthcare settings. Understanding evidence-based recommendations on how facility design affects health outcomes is critical to reversing the rise in maternal mortality and morbidity. A variety of measures can be implemented that promise to improve user satisfaction, quality of care, and efficiency for all who engage in the childbirth environment. Recommendations for change include broader assessment to better understand how clinicians and consumers simultaneously maneuver within a complex system. Key metrics include evaluation of workflow within available space, patient acuity and census patterns, integration of evidence-based recommendations, and options that promote physiologic birth. For the changes to succeed, human centered design must be implemented and diverse clinicians and consumers engaged in all phases of planning and implementation. Exploring characteristics and outcomes of low-risk women who receive care in a freestanding birth center or the European alongside maternity unit provides opportunity to reimagine and address improvements for inpatient, hospital birth.

The issue of delivery room infections in the Italian law. A brief comparative study with English and French jurisprudence.

Delivery room infections are frequent, and many of them could be avoided through higher standards of care. The authors examine this issue by comparing it to English and French reality. Unlike England, in Italy and France the relationship established between health facility, physician and patient is outlined in a contract. In England, the judges' decisions converge toward a better and higher protection of the patient-the actor-and facilitate the probative task. In case of infections, including those occurring in the delivery room, three issues are evaluated: the hospital's negligent conduct, damages if any and causal nexus. Therefore, the hospital must demonstrate to have taken the appropriate asepsis measures according to current scientific knowledge concerning not only treatment, but also diagnosis, previous activities, surgery and post-surgery. In order to avoid a negative sentence, both physicians and hospital have to demonstrate their correct behavior and that the infection was caused by an unforeseeable event. The authors examine the most significant rulings by the Courts and the Supreme Court. They show that hospitals can avoid being accused of negligence and recklessness only if they can demonstrate to have implemented all the preventive measures provided for in the guidelines or protocols.

[Midwife-led birth centres: an alternative to hospital childbirth?]. / Geburtshäuser: Versorgungsalternative zur Klinikentbindung?

After midwife-led birth centres had been included into the Social Security Statute Book (§134a SGB V) and thus become covered by German Public Health Insurance since April 1st, 2007 contract negotiations on flat rate costs have followed. Meanwhile the 2nd edition of this -agreement has come into effect. The present contribution describes how this non-hospital obstetric care has developed in the last 3 years. The medical care situation is explained based on legal conditions. Special attention is paid to regulations concerning quality management as well as the certification or auditing required to remain listed in the national register of midwife-led units at the Social Health Insurance. Results are shown from data collected by the Associa-tion for Quality Assurance on Out-of-hospital births (QUAG) and from a pilot project which also contains comparisons with clinical findings. The discussion refers to data taken from German as well as international publications. The conclusion points out some aspects in need of further development.

New cardiopulmonary resuscitation guidelines 2010: managing the newly born in delivery room.

Most newborns are born vigorous and do not require neonatal resuscitation. However, about 10% of newborns require some type of resuscitative assistance at birth. Although the vast majority will require just assisted lung aeration, about 1% requires major interventions such as intubation, chest compressions, or medications. Recently, new evidence has prompted modifications in the international cardiopulmonary resuscitation (CPR) guidelines for both neonatal, paediatric and adult patients. Perinatal and neonatal health care providers must be aware of these changes in order to provide the most appropriate and evidence-based emergency interventions for newborns in the delivery room. The aim of this article is to provide an overview of the main recommended changes in neonatal resuscitation at birth, according to the publication of the international Liaison Committee on Resuscitation (ILCOR) in the CoSTR document (based on evidence of sciences) and the new 2010 guidelines released by the European Resuscitation Council (ERC), the American Heart Association (AHA), and the American Academy of Pediatrics (AAP).

Eu vi meu filho nascer: vivência dos pais na sala de parto / I saw my child being born: experience of fathers in delivery rooms

Foi realizado um estudo exploratório descritivo, com abordagem qualitativa na maternidade municipal deLondrina, Paraná, com o objetivo de apreender o conhecimento dos pais sobre o direito do acompanhante duranteo trabalho de parto e parto e conhecer a vivência dele durante o nascimento do filho. Para isto, foram entrevistados,no período de 15 a 22 de junho de 2006, quarenta pais, jovens em sua maioria, que vivenciavam o nascimentodo primeiro filho. Para análise das informações, utilizou-se o método de análise de conteúdo. Verificou-se que elesdesconheciam o direito que lhes é resguardado por lei de estarem presentes durante este evento, ao atribuíremsua presença à benevolência da equipe médica. Pode-se julgar a experiência positiva pelo suporte à parturiente,por desmistificar temores e sofrimentos relacionados ao parto.

["I saw my child being born": experience of fathers in delivery rooms]. / "Eu vi meu filho nascer": vivência dos pais na sala de parto.

A descriptive exploratory study with qualitative approach was carried out in the Municipal Maternity of Londrina, Paraná, Brazil, with the aim of assessing the knowledge of parents as to the rights of the partner during labor and delivery, and to find out about his experience during the birth of his child. Forty young fathers experiencing the birth of their first child were interviewed from June 15th to June 22nd, 2006. It was verified that they were unaware of their right to be present during these events, attributing their presence to the generosity of the medical team. The experience was considered as positive because of the support given to the mothers, denmystifying fears and suffering related to childbirth.

The perinatal patient safety nurse: a new role to promote safe care for mothers and babies.

Medical malpractice premiums and costs of obstetric claims, settlements, and jury awards are at an all-time high. This article describes one professional liability company's initiative to promote safer perinatal care and decrease costs of claims, including the development of the perinatal patient safety nurse role. The primary responsibility of the perinatal patient safety nurse is to promote safe care for mothers and babies by keeping patient safety as a focus of all unit operations and clinical practices.

The applicability of DNA techniques in investigations of hospital malpractices: a case report.

DNA analysis has been used successfully in a number of parentage cases and for the purposes of identification. However DNA typing is still not generally integrated efficiently into hospital systems in India. I report here the use of DNA evidence in a parentage dispute that arose as a result of a bizarre sequence of events in a maternity ward of General Hospital, Chandigarh, India. The changing standards of hospital practice and social attitudes such as gender bias are likely to augment medico-legal problems in India. There is good reason for DNA profiling methods to be introduced into the hospitals.

The relationship of health care delivery system characteristics and legal factors to mode of delivery in women with prior cesarean section: a systematic review.

OBJECTIVE: To evaluate the relationship of health care delivery system characteristics and legal factors to mode of delivery in women with prior cesarean section. METHODS: We identified relevant studies by searching MEDLINE and HealthSTAR (1980 to May 2002), reference lists of pertinent articles, and recommendations of local and national experts. We also searched the online Cochrane systematic reviews and controlled trials registries, Database of Abstracts and Reviews on Effectiveness, and EMBASE databases. RESULTS: Studies of guidelines suggested that opinion leaders influence provider behavior regarding repeat cesarean delivery versus trial of labor decisions. Studies of hospital and insurance characteristics provided inconsistent results. There was insufficient evidence to evaluate the relationship between provider characteristics and delivery outcomes. Legislation and liability-related factors effected limited change. CONCLUSION: Studies of health care system characteristics and other factors focused primarily on rates of delivery modes (vaginal birth after cesarean or repeat cesarean delivery) rather than patient safety or health outcomes. Future studies must account for case mix, time trends, and other potential confounders, especially concerning associations of provider characteristics.

DSH adjustment controversies continue.

Some Medicare intermediaries are reducing the disproportionate share hospital (DSH) payment by excluding labor/delivery room days and dual-eligible days from the DSH calculation. Some intermediaries are excluding maternity patients who are in a labor/delivery room at the census-taking hour unless the patient previously occupied a routine bed. Intermediaries also are excluding Medicaid-eligible days attributable to patients who are not entitled to payment under Medicare Part A. These adjustments are of questionable legal validity and hospitals should protect their rights to appeal these issues.

Strategies for change: nursing implementation of the birthing room.

Nurses were primary participants in introducing the birthing room for maternity care in their respective institutions. Based on tape-recorded interviews, this paper is a report on how the idea of a birthing room was initiated, the resistance it encountered, the eight strategies used to implement the idea, and appropriation of the idea by physicians. Although the examples are specific to the development of a birthing room, the strategies can be used by nurses to initiate other changes in perinatal health care delivery. In addition, increased collaboration between nurses and physicians may make some strategies obsolete.