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A new study of obstetrics liability claims between 2013 and 2017 showed that 80 percent of obstetrics claims involved high clinical severity cases. Boston-based liability insurer Coverys analyzed 472 OB claims and found that in 24 percent of these cases, either the mother, infant or both died. Additionally, according to the report, 40 percent of obstetrics claims relate to management of labor and delivery. One issue is the lack of training and standardization when it comes to monitoring fetal heart patterns.
Fetal heart rate monitoring technology has been around for several decades. Clinicians use a doppler fetal monitor on the mother’s abdomen to listen to the baby’s heart rate continuously, especially during labor. Nowadays, heart rate patterns are stored electronically, they can be viewed on monitors throughout the unit and medical staff members can log into a portal to see the tracings for each patient. Usually, the fetal heart rate is monitored in coordination with uterine activity, such as contractions, to have greater insight into labor.
Clinicians use both pieces of information – fetal heart rate and uterine activity – to interpret the heart rate monitor and determine the category of the tracing – I, II or III. In short, category I is low risk and category III is high risk. If the tracing indicates a category III, the delivery is typically expedited.
“Many tracings land in category II, which is where all kinds of management decisions have to be made,” said Dr. Mark Simon, OBHG Chief Medical Officer and OB/GYN. “You must put the tracing into the context of what else is going on with the patient and make a decision based on the bigger picture.”
In the U.S., continual fetal heart rate monitoring is the standard of care in labor due to the risk of medical malpractice. According to the Converys report, 77.3 percent of fellows of the American College of Obstetricians and Gynecologists (ACOG) report they have been sued.
OB/GYNs and OB nurses are trained to learn heart rate patterns and meanings. Analyzing these patterns should guide teams in determining whether they should intervene and if so, how. Ongoing education and training around how to evaluate fetal heart rate patterns is vital.
“There are numerous reasons why maintaining competency in interpreting fetal heart rate monitoring is incredibly important,” said Dr. Simon. “It’s important to know what those patterns are, what they mean how and what intervention to do based upon the patterns in the context of the patient as a whole.”
Understanding and interpreting the patterns is reliant upon understanding the language – being able to correctly determine the category. OB teams must go through training to ensure that everyone on the team is speaking the same language, standardized by NICHD.
“If you have physicians and nurses speaking a different language about the same thing, error is going to happen,” said Dr. Simon. “This is the number one reason you want OB teams to be routinely up to date and competent in this area.”
Not all private-practice OB/GYNs complete routine training on fetal heart rate monitoring and therefore may not speak the most up-to-date language. This presents a problem. There could be subtle changes in interpretation standards, and physicians who aren’t consistently training are setting themselves up for error.
“Every OB clinician across the country should be able to interpret a fetal heart rate tracing the same way,” said Dr. Mark Simon. “But the only way you get there is practice and routine education.”
Ob Hospitalist Group (OBHG) strongly believes that ongoing education on fetal heart rate monitoring is important. OBHG requires our team of more than 700 physicians and midwives nationwide to complete training every two years. In addition, OBHG leadership plans to create stricter standards when it comes to training test scores. According to Dr. Simon, this is not the norm across OB/GYN practices.
“Taking care of women in labor is an honor for our organization and we want to ensure that our physicians and midwives have the tools to be successful,” said Dr. Simon