Safety of care
Safe care in obstetrics: Keys to effective interprofessional care
Originally published December 2016
Interprofessional care—also known as multidisciplinary, collaborative, shared, or team care—can enhance the quality of care provided to patients by combining the knowledge and skills of health professionals in various disciplines, facilitating continuity across the system, and improving access to care. Nevertheless, some physicians have concerns about the potential for increased risk of liability when working collaboratively.
Obstetrical care is shared by many health professionals who are responsible for different aspects of patient care before, during, and after delivery. The makeup of this interprofessional team may vary by patient preference, practice context, or circumstance.
The CMPA reviewed 135 recent cases1 involving interprofessional care for obstetrical patients, and found that when medical-legal difficulties arise, they are frequently a consequence of poor coordination of care and inadequate communication brought about by a lack of clarity of roles and responsibilities or due to interprofessional conflict.
Regulated independent healthcare professionals are responsible, and individually accountable, for their clinical decisions.2 To support this, the Healthcare Insurance Reciprocal of Canada (HIROC) and the CMPA emphasize the importance of consistent and meaningful communication among all members of the healthcare team. Appropriate and adequate professional liability protection for all health professionals involved in the patient’s care is also essential.3
Consent for shared care
Pregnant patients should be informed early about the nature of shared care they may receive throughout pregnancy and delivery, including the involvement of other providers, which may include trainees.
Prenatal testing and antepartum care
In the CMPA case review, the 20 antepartum cases that were identified involved a diverse group of health professionals: obstetricians, radiologists, family physicians, pharmacists, physiotherapists, and midwives.
Cases related to prenatal investigations often involved poor follow-up that stemmed from confusion about which healthcare provider was responsible to communicate test results or coordinate further testing. These cases typically involved a delayed diagnosis of a serious fetal condition, such as trisomy 21 or hypoplastic left heart syndrome. Incomplete review of the medical record (in particular the entries of other providers) and poor communication with the patient about the need for follow-up were contributing factors in these cases.
Poor coordination in the antepartum period also involved the diagnosis and management of new or pre-existing maternal conditions. These included evolving conditions—such as gestational diabetes, pregnancy-induced hypertension, and spinal cord compression— which could have been better managed with earlier intervention. These cases were characterized by a lack of collaboration and communication among providers.
Case example: Critical information falls through the cracks
A baby is born at 29 weeks gestation in a pregnancy complicated by oliogohydramnios. At a few months of age, he is diagnosed with renal dysplasia resulting from his mother’s use of an angiotensin receptor blocker (ARB) for hypertension throughout pregnancy.
The woman had been taking the ARB for two years. She was not intending to become pregnant and was using an intrauterine device at the time of conception. At her initial visit to discuss the pregnancy, her family physician (FP) ordered an ultrasound for dating and to assess the viability of the pregnancy. He also referred the patient to the hospital for genetic testing based on her age-related risk. There was no discussion of her anti-hypertensive medication.
At the first formal antenatal appointment a couple of weeks later, the obstetrician noted that the patient was taking a medication for hypertension. As the patient couldn’t remember the drug’s name, the obstetrician asked her to bring it with her at the next visit. He also prescribed a drug to treat the patient’s hyperemesis.
The patient filled the prescription for the anti-emetic, and at the same time, obtained a refill of her anti-hypertensive medication. The dispensing pharmacist did not caution the patient that ARBs should not be used in pregnancy.
At her subsequent appointments, the subject of her anti-hypertensive medication was not revisited. When oligohydramnios was suspected at 29 weeks, the patient was referred to a consultant for further assessment. The ARB was stopped at this time.
Peer experts who were consulted on the legal case were critical of all of the antenatal healthcare providers, including the pharmacist, for failing to recognize that the patient was on a medication contraindicated in pregnancy.
Shared situational awareness and effective communication are essential to interprofessional care in labour and delivery. Two recently published CMPA articles examine these topics in depth.4,5 Additionally, well-designed team structures and communication processes that make best use of the skills of each provider help to achieve reliable intrapartum care.6
Case example: Resources not optimized for competing demands
A baby is born severely compromised after an emergency caesarean section was delayed.
The patient was labouring under the care of an FP. When the fetal heart rate tracing became a concern, an obstetrician was consulted who recommended delivery by caesarean. The patient was transferred to the operating room within 10 minutes.
During this time, the obstetrician was called away for a vaginal delivery for another patient. The obstetrician’s return was delayed owing to a postpartum hemorrhage.
Meanwhile in the operating room, several calls were made by the team to enquire on the whereabouts of the obstetrician. They were repeatedly told that she was on her way. The obstetrician arrived 45 minutes later to begin the caesarean. A neurologically compromised baby was delivered.
When the events were reviewed as part of legal proceedings, the FP expressed surprise at the length of time between the transfer and caesarean. She observed that a nursing shift change had occurred at the time of transfer. The incoming team did not recognize that the fetal scalp clip had been removed and was never reattached, which compromised the team’s ability to appreciate the urgency of the situation.
Peer experts were critical of the obstetrician for prioritizing the less urgent delivery, and of the family physician for not remaining alert to the passage of time and not appropriately communicating to the larger team about the ongoing urgency to proceed with the caesarean section.
Knowledge of the training and expertise of other professionals plays a key role in facilitating collaboration and reducing conflict.6 In the CMPA cases, incidents of interprofessional conflict tended to occur during consults or at transfers of care.
Case example: Interprofessional tensions contribute to a breach in the duty of care
An obstetrician declines to assess a patient who arrives at the emergency department (ED) with her midwife and without antenatal records.
The midwife called the local ED to advise that her patient, at 33 weeks’ gestation had experienced a premature rupture of membranes. The patient had intended to deliver at a birthing centre in an adjacent community. The triage nurse advised her not to bring the patient to the ED, as the hospital did not deliver babies earlier than 34 weeks.
The midwife nonetheless arrived with the patient and her partner one hour later.
On her way to perform a caesarean delivery, the obstetrician spoke to the midwife and stated that she could not assess the patient without reviewing the antenatal record, which was stored at the birthing centre. The obstetrician reiterated that this hospital did not perform deliveries before 34 weeks. She recommended that the patient travel to the hospital affiliated with the midwife’s birthing centre, as it had better facilities for managing the care of preterm infants.
The midwife transferred the patient to the nearby level II hospital where the patient subsequently delivered a healthy preterm infant.
In the hospital complaint that followed, the parents noted that the obstetrician had appeared exasperated. The obstetrician explained that she was new to the region and had limited experience working with midwives. She also stated that she was taken aback by the midwife’s abrupt manner.
Hospital investigators were critical of the obstetrician’s refusal of care, noting that she had a duty to assess the patient, regardless of the original birth plan or the unavailability of antenatal records.
Strategies for enhancing interprofessional care
Various strategies may be employed to enhance interprofessional care in labour and delivery, such as establishing a series of structured teams to manage the unit’s different functions including emergency response,7 tailored communication tools for information sharing,8 and team training.9 These strategies all recognize the need to fully integrate all team members in the functioning of the unit.
The bottom line
- Inform pregnant patients early about the nature of the shared care they may receive and the protocols in place for potential emergencies.
- Be familiar with the scope of practice, qualifications, experience, training, and liability protection of other healthcare providers who you know will be involved in the patient’s care.
- Have an agreement about who is the most responsible healthcare provider at any given time and what the division of responsibilities will be at any given time.
- Carefully review the patient’s medical record, including all entries made by other providers.
- Consider using a structured communication tool for sharing information during handovers.
- Remain aware of your independent duty of care to the patient, particularly in difficult or ambiguous shared care scenarios.
- Legal, medical regulatory authority (College), and hospital matters that closed in the last 10 years.
- Canadian Medical Protective Association. Collaborative Care: A medical liability perspective [Internet]. Available from: https://www.cmpa-acpm.ca/web/guest/-/collaborative-ca-1
- Canadian Medical Protective Association and Healthcare Insurance Reciprocal of Canada. Joint Statement on Liability Protection for Midwives and Physicians [Internet]. June 2007. Available from: https://www.cmpa-acpm.ca/en/public-policy/-/asset_publisher/9rnAcJbTAZA6/content/joint-statement-on-liability-protection-for-midwives-and-physicians
- Canadian Medical Protective Association. Safe care in obstetrics: Improving teamwork and communication in an emergency. June 2016 [cited 2016 July 5]. Available from: https://www.cmpa-acpm.ca/-/improving-teamwork-and-communication-in-an-emergency
- Canadian Medical Protective Association. Safe care in obstetrics: Recognizing signs of potential trouble in labour and delivery [Internet]. September 2016 [cited 2016 September 30]. Available from: https://www.cmpa-acpm.ca/en/safety/-/asset_publisher/N6oEDMrzRbCC/content/improving-teamwork-and-communication-in-an-emergency
- Morgan L, Carson G, Gagnon A, et al. Collaborative practice among obstetricians, family physicians and midwives. CMAJ. 2014 Nov 18;186(17):1279-80.
- Mann S, Marcus R, Sachs B. Grand Rounds: Lessons from the cockpit: How team training can reduce errors on L&D. Contemporary OB/GYN. 2006;Jan:1-7.
- Poot EP, de Bruijne MC, Wouters MG, et al. Exploring perinatal shift-to-shift handover communication and process: an observational study. J Eval Clin Pract. 2014 Apr;20(2):166-75.
- Thanh NX, Jacobs P, Wanke MI, et al. Outcomes of the Introduction of the MOREOB Continuing Education Program in Alberta. J Obstet Gynaecol Can. 2010;32:749-55.