The Belgian, French and Dutch midwife on trial: A critical case study.

OBJECTIVE: to develop juridical recommendations in order to avoid midwifery medical liability when providing intrapartum care. DESIGN: case law of the past 40 years concerning midwifery medical negligence when assisting labour/delivery in a hospital was analysed. Databases used were Jura and Judit (Belgium), Legifrance, Juricaf and Dalloz (France) and Recht, Rechtspraak (The Netherlands). A minority of cases were retrieved through contacts with insurance companies (only Belgium), lawyers and courts. SETTING: law suits in Belgium, France and The Netherlands. FINDINGS: the 100 analysed cases could be categorised into four types. The judicial assessment was focused on three domains of expertise of the midwife. Most cases involved interpreting fetal monitoring (47%), followed by recognising a specific pathology (32%) and responding to a complication (12%). A fourth type of case concerned exceeding the boundaries of the legal competencies of the midwife (9%). KEY CONCLUSIONS: not identifying fetal distress through fetal monitoring was the most common cause of midwifery liability (15/47), followed by not recognising the symptoms of a pathology (10/32), particularly placental abruption and uterine rupture. Also an inaccurate response to complications (3/12) and evidently exceeding the professional competencies involved midwifery liability. IMPLICATIONS FOR PRACTICE: achieving cardiotocograph interpretation skills is the first and most important recommendation. In pathologic cases, the midwife should immediately refer to an obstetrician, without any hesitation. The third recommendation is working in a team with the obstetrician. If the midwife has reasonable (evidence-based) doubts about the practice of the obstetrician, she should insist on re-assessment with respect to the boundaries of her competencies. The fourth recommendation concerns practising with knowledge of the client׳s/patient׳s medical record and updating the record with performances and observations. Consciously choosing the type of medical intervention in urgent cases of pathology is the final recommendation.

Assessment parameters and indicators in expert intrapartal nursing decisions.

OBJECTIVE: To determine what clinical parameters and indicators expert intrapartal nurses used to assess the severity of fetal stress. DESIGN: A descriptive, qualitative study using tape-recorded interviews from verbal protocols during clinical problem solving. SETTING: Labor and delivery units of two metropolitan hospitals in the northeastern United States. PARTICIPANTS: Eighteen nurses, designated as experts by nurse managers, with an average of 11.3 years of intrapartal experience. RESULTS: The clinical assessment parameters identified by content analysis included duration of stress, fetal reserve status, reversibility of stress, and specific signs of stress. The clinical assessment parameters included whether the disturbing pattern was brief or prolonged, continuous or intermittent, and how rapidly the mother's labor was progressing. Indicators of fetal reserve status were maternal pregnancy health status, gestational age of fetus, and biophysical indicators of fetal status. Reversibility of stress was assessed based on the precipitating factors involved and responsiveness of the fetus to resuscitation. Specific signs of stress included the characteristics of the fetal monitor strip changes, scalp sample results, and amniotic fluid color. CONCLUSIONS: Contextual features of clinical problems are key links in the decision-making processes of expert intrapartal nurses. Knowledge elicitation techniques can be used to identify these links.

Experienced obstetric nurses' decision-making in fetal risk situations.

OBJECTIVE: To determine which clinical factors experienced obstetric nurses consider most important in determining fetal risk during the intrapartum period. DESIGN: Ten dichotomized variables relevant to participants' clinical decision-making were manipulated in fractional factorial vignettes. Participants were asked to rate the severity of fetal risk on a Likert scale after reading the vignettes. SETTING: About 87% of the participants worked in institutions with 4,000 or fewer deliveries per year. More than 25% worked in tertiary level facilities, and the remainder were employed in primary or secondary level facilities. PARTICIPANTS: Participants (N = 573), randomly selected from a list of nurses certified in "inpatient obstetric nursing" by the National Certification Corporation, were mailed the vignettes. The average number of years of intrapartum nursing experience was 13. MAIN OUTCOME MEASURE: Multiple regression analysis was used to determine the weights given to the 10 clinical factors by participants. RESULTS: Fetal scalp pH, maternal parity, amniotic fluid color, and long-term variability of the fetal heart rate were the most important predictors of nurses' fetal risk assessments. CONCLUSIONS: Long-term variability was the most important cardiotocographic factor in nurses' fetal risk assessments and the only cardiotocographic factor of the best 4 predictors of fetal risk. This indicated that participants were realistic about the limitations of electronic fetal monitoring (EFM).

Amnioinfusion: a technique for the relief of variable deceleration.

Human and animal studies have demonstrated an association between decreased amniotic fluid and the occurrence of variable decelerations in the fetal heart rate. Amnioinfusion is a new investigational technique directed at decreasing the number and severity of variable decelerations by infusion of a normal saline solution into the uterine cavity. The technique may provide a mechanism for protecting the umbilical cord from compression and, thereby, ameliorating fetal distress. This article describes amnioinfusion and discusses related nursing implications for patients undergoing the procedure.

Intrapartal tocolysis: an option for acute intrapartal fetal crisis.

Tocolytic drugs are commonly used by the obstetric community to produce uterine quiescence in premature labor. The use of tocolytic agents has been expanded to intrapartal emergencies. Intrapartal tocolysis has implications for obstetric nurses, which include possession of knowledge of the pharmacologic and physiologic effects of these drugs. Intrapartal tocolysis offers a beneficial management strategy that can be used in an acute intrapartal fetal crisis. The use of tocolytics provides valuable time for the health care team to assess the etiology of a nonreassuring fetal heart rate pattern, increase options for the birth, and mobilize resources for delivery.

The biophysical profile: antepartal assessment of fetal well-being.

The assessment of fetal well-being is a primary consideration for perinatal nurses. The biophysical profile is a clinical evaluation of the status of the fetus based on assessment of multiple discrete variables. This article describes current biophysical profile scoring systems, the physiologic basis of the fetal variables, and factors that may affect the variables. It also discusses issues related to future applications and refinement of the biophysical profile, as well as nursing implications of the technology.

Relieving fetal distress with amnioinfusion.

The nurse's role in this relatively safe, effective procedure is to prepare equipment, monitor for possible adverse effects, and support the mother.

Trauma in pregnancy.

The pregnant woman is exposed to the same risks as the non-pregnant woman for sustaining a traumatic injury, but because of the multiple physiologic changes that occur during pregnancy, the assessment and treatment of such patients must be adapted accordingly. This article discusses these normal physiologic changes, their effect on response to trauma, and the comprehensive care of the patient using the nursing process.

The development of an obstetric triage acuity tool.

The purpose of this article is to describe the journey a multicampus hospital system took to improve the obstetric triage process. A review of literature revealed no current comprehensive obstetric acuity tool, and thus our team developed a tool with a patient flow process, revised and updated triage nurse competencies, and then educated the nurses about the new tool and process. Data were collected to assess the functionality of the new process in assigning acuity upon patient arrival, conveying appropriate acuities based on patient complaints, and initiating the medical screening examination, all within prescribed time intervals. Initially data indicated that processes were still not optimal, and re-education was provided for all triage nurses. This improved all data points. The result of this QI project is that our patients are now seen based on their acuity within designated time frames.