Safety of care
Safe care in obstetrics: Improving teamwork and communication in an emergency
Originally published June 2016
Obstetrical emergencies can be catastrophic and require immediate and capable management from the healthcare team. Although rare, these emergencies can occur at any time and often without much warning. Optimizing teamwork and communication will improve the team’s response to obstetrical emergencies and, as a result, enhance the safety of care for mother and baby.
Studies show that communication breakdowns are leading contributors to serious obstetrical patient safety incidents.1,2
An analysis of 169 CMPA closed medical-legal cases involving obstetrical emergencies over the past 10 years focused on the recurring themes of teamwork and communication. The main problem for all members of the care team was not clearly communicating in these situations. Emergencies included shoulder dystocia, placental abruption, cord prolapse, and maternal hemorrhage. Nearly three-quarters of patients in these cases experienced harm.
Lack of communication with patients is frequently the basis for hospital and medical regulatory authority (College) complaints in which patients allege they were not fully informed about their care, such as the reasons for necessary treatment or the risks associated with anticipated procedures.
Several factors were identified as impediments to teamwork in the reviewed cases, and involved all team members including physicians, nurses, and residents. These factors included lack of verbally articulated team situational awareness, intimidation felt by some team members, unclear roles and responsibilities, and non-adherence to policies and clinical practice guidelines.
Nurses and residents in the analyzed cases were found to not be informing the attending physician of changes in fetal or maternal status, and to be omitting critical information in their updates, both verbally and in the medical record. The most commonly overlooked information was the presence of atypical or abnormal fetal heart rate (FHR) tracings. Physicians, meanwhile, were found not to be seeking out sufficient clinical information on the patient’s condition when discussing the case with team members, or failing to recognize the significance of the information communicated to them.
Case example: Communication breakdown between healthcare team members
A multiparous woman with gestational diabetes is induced at term due to new onset of gestational hypertension. She is given prostaglandin and IV oxytocin. Several hours later, the patient receives an epidural, the obstetrician ruptures her membranes, and meconium is noted. During this time, the FHR tracing is normal. Three hours later, the obstetrician notes the patient’s cervix is 5 cm dilated. Over the next 30 minutes, while the patient is observed by the nurse and resident, the external fetal monitor records significant decelerations, absent variability, slow recovery barely to baseline, and episodes of compensatory tachycardia. The resident re-examines the patient, notes that the cervix is 9 cm dilated, and calls the obstetrician about the dilatation and the decelerations. The obstetrician instructs the resident that the decelerations can be attributed to rapid dilatation, and to continue monitoring. He instructs the resident to inform him of any further decelerations.
Fifteen minutes later, the nurse asks the obstetrician to attend in person to review the persistent decelerations. Upon arrival, the obstetrician concludes that the tracing has been abnormal for the last 45 minutes, and he decides to perform a vacuum-assisted delivery. After two contractions, a limp baby is delivered in need of aggressive resuscitation.
The resident and nurse are questioned by the hospital review committee as to why they did not notify the obstetrician sooner about the changes in the FHR tracing. They explain that they did not think at the time that the situation was worrisome, and that they felt intimidated by the obstetrician’s gruff manner. The committee reviews the documentation made by the nurse, resident, and obstetrician, and finds that their sparse notes are contradictory and do not adequately convey the situation and clinical thinking. The committee concludes that the patient’s care was mismanaged, that there was delay when delivery should have been expedited, and that crucial information was not properly communicated between members of the team.
Ineffective communication hindered a response in many situations in the reviewed cases. Factors that contributed to miscommunication included chaotic workplace environments, ineffective hospital paging protocols, inadequate handovers, and poor communications skills. Where communication breakdown was identified in the reviewed cases, hospitals often responded with changes to processes and protocols. These changes included the creation of contingency plans when physicians do not respond to pages or cannot attend, and the development of structured tools for sharing information at shift change or during handovers. The following case illustrates how failing to communicate clearly during an emergency can contribute to a serious outcome.
Case example: Miscommunication of urgency
A family physician is attempting a vacuum extraction to deliver a baby whose FHR tracings show profound decelerations. The unit has been very busy overnight, and the incoming team has many patients to discuss at handover. The physician asks the outgoing nurse to page the on-call obstetrician for assistance. His request is not passed on to her replacement. The physician leaves the patient’s bedside to seek out the obstetrician, who upon arriving reviews the FHR tracing and determines that an urgent caesarean section is needed. As the urgency is not well communicated to the operating room (OR) personnel, there is a delay in the transfer of the patient. The anaesthesiologist does not attend urgently because he is under the impression that the indication is elective and not urgent. Forty-seven minutes later, a stillborn infant is delivered.
The patient files a legal action. Peer experts reviewing the case are critical of several aspects of care, including the unreasonable delay in performing an urgent procedure. Following this event, the hospital implements an improved process to prioritize caesarean section bookings.
Improving communication in obstetrical emergencies
The following suggestions, aimed at fostering a culture of safety with open and respectful communication in obstetrical units, are based on expert opinions in the reviewed CMPA cases.
For physicians in practice:
- Obtain informed consent, and keep the patient informed of changes in the treatment plan as they develop.
- Clearly verbalize concerns with team members about the patient’s condition to enhance the team members’ situational awareness, and confirm that the team recognizes the urgency.
- Use a structured communication tool for sharing information at handover and when providing progress reports, regardless of whether these exchanges are verbal or via the medical record.
- Consider using a standardized documentation template for situations in which timelines are important (e.g. shoulder dystocia, assisted vaginal deliveries).
- Debrief with the team following an urgent delivery or patient safety incident to review the sequence and timing of events and the effectiveness of team communication. All team members should document the care provided and the information should be consistent.
- Following an obstetrical emergency, discuss the circumstances and outcomes with the patient and her family. Consult the CMPA handbook Disclosing harm from healthcare delivery, or contact the Association for individual advice on disclosure.
For physicians in leadership roles:
- Develop and encourage use of strategies to escalate clinical concerns within a team environment.
- Facilitate and encourage simulation training and drills to practise team shared situational awareness, effective communication, and crisis response.
- Clearly define the roles and responsibilities of each team member to optimize care coverage and responsiveness.
- Encourage regular reviews and updates of communication policies and training. Periodically evaluate adherence to such policies and quality improvement activities.
The CMPA Good Practices Guide has more information on team communication, including structured communication methods, situational awareness, and approaches for speaking up.
- The Joint Commission. Sentinel event data: Root causes by event type 2004 – 3Q 2015 [Internet]. 2015 Nov 13 [cited 2016 Jan 7]. Available from: http://www.jointcommission.org/sentinel_event_statistics/
- The Joint Commission. Preventing infant death and injury during delivery. Joint Commission Sentinel Event Alert [Internet]. 2004 July 21 [cited 2016 Jan 7]: Issue 30. Available from: http://www.jointcommission.org/sentinel_event_alert_issue_30_preventing_infant_death_and_injury_during_delivery/