Safety of care
Safe care in obstetrics: Recognizing signs of potential trouble in labour and delivery
Originally published September 2016
Situational awareness is an essential skill for all healthcare providers, particularly those working in high-risk, continuously evolving clinical environments such as labour and delivery.
For individuals, situational awareness is a cognitive process in which the provider perceives and understands information within the clinical context and projects ahead to anticipate potential future scenarios.1 And for teams, situational awareness reflects a shared understanding and communication of what’s going on and what’s likely to happen next.2
According to patient safety experts, healthcare providers and teams that lack situational awareness are generally slower to:
- detect problems
- determine the significance of observed abnormalities
- take action once a problem is recognized3
Reflecting this reality, the CMPA’s obstetrical cases involving peer expert criticism of the delayed delivery of a baby showing signs of potential compromise include varied examples of a lack or temporary loss of individual and team situational awareness. Fifty recent CMPA cases4 were analyzed, nearly all of which involved serious patient harm, including infant death in 25 cases and maternal death in two.
Case 1: Fetal heart tracings should have alerted obstetrician, say peer experts
A baby dies shortly after a complicated assisted vaginal delivery. Peer experts commenting on the ensuing legal case are of the opinion that a persistent pattern of troubling fetal heart rate tracings should have alerted the obstetrician to the need for a caesarean section two hours before the baby was ultimately delivered.
That evening, the on-call obstetrician was overseeing a busy unit with five other patients in active labour. She had been working since the early morning and at one point remarked to the parents that she was exhausted.
Expert analysis of the clinical care found that the obstetrician, on numerous occasions, did not react to the nurses’ voiced and documented concerns about the fetal heart tracing. Records also show that she left the labouring patient multiple times to attend to less urgent cases.
The obstetrician was present while the patient pushed for more than an hour, during which time the fetal heart rate tracing continued to deteriorate. She made several attempts to manually rotate the baby from the occiput posterior position without success. The nurse voiced concern that the obstetrician was struggling to decide what to do next and offered to call in another obstetrician to assist. Within minutes of arriving and assessing the situation, the second obstetrician applied forceps and delivered the baby.
Experts felt that the obstetrician demonstrated a serious lack of judgment by not acting sooner and more decisively on a worrisome tracing, persisting with an unsuccessful manoeuvre, and not having a back-up plan.
Case 2: Early signs of uterine dehiscence missed
A uterine rupture that occurred during labour leaves a baby with life-long disabilities. Peer experts are critical of the obstetrician and nurses for missing early signs of uterine dehiscence (i.e. fetal tachycardia in association with unremitting incisional pain) — a known risk for this patient who was attempting to have a vaginal birth after caesarean section (VBAC). Peer experts state that the impending rupture could have been foreseen, and that earlier delivery would likely have prevented this outcome.
The team caring for this labouring patient had limited experience in the management of VBAC. After he was first called by the first-year resident for a troubling fetal heart rate tracing, the attending obstetrician performed a scalp pH test, which was normal. He then left the delivery room, but did not instruct the care team on the next steps for monitoring or management. In the intervening hour, the tracing continued to deteriorate. The attending obstetrician was called back and ordered a "STAT" caesarean section. A massive uterine rupture was found at delivery.
Experts were critical of the nurses for not appreciating the significance of the fetal heart rate tracing in light of this patient’s risk for uterine rupture.
The resulting legal settlement was shared by the CMPA, on behalf of the obstetrician for his inadequate communication with the care team given the team’s limited experience with VBACs, and by the hospital, on behalf of the nurses.
Case 3: Recognition of fetal compromise delayed
A baby is left profoundly disabled, likely the result of cord compression during labour and delivery. Peer experts are critical of the obstetrician and nurse for their failure to recognize signs of possible fetal compromise and the lack of a coordinated response to expedite delivery once the urgency of the situation was recognized.
The patient was being cared for by a nurse who had just recently started working in the labour and delivery unit. As such, peer experts later determined that she was unable to effectively monitor and accurately interpret tracings, alert the obstetrician in a timely manner about ominous developments, and prepare for emergencies that could be anticipated. The experts were of the opinion that she should have been assigned to work with a more experienced nurse.
The obstetrician checked in on the patient several times over the course of her labour, though the mother recalled that these visits were brief and involved minimal questioning by the obstetrician of the nurse. Both parents observed tension between the nurse and the doctor.
When the obstetrician last visited the patient and discovered the troubling nature of the tracing, she decided to proceed immediately with an assisted vaginal delivery. However, the necessary equipment was not in the room as expected, which further delayed delivery. The hospital’s neonatal resuscitation team was not called to attend the birth.
The resulting legal settlement was shared by the CMPA, on behalf of the obstetrician, and by the hospital, for the nursing care, inadequate staff support, and for not ensuring that all appropriate equipment was accessible and protocols were followed.
For individuals and teams to achieve situational awareness in obstetrical care, they need to have an appropriate level of experience and expertise to monitor fetal heart tracings, and anticipate and respond to potential problems based on the clinical context. In addition, teams need to be aware of the availability of other healthcare providers, e.g. anesthesiologists, and resources, e.g. operating rooms.5
In the CMPA cases, additional factors affecting situational awareness included:
- provider issues
- clinical inexperience
- team issues
- dysfunctional dynamics, often associated with inadequate or unassertive communication, interpersonal issues, or limited experience working together
- multiple competing tasks (task-overload), including high-volume/high-acuity situations
- information gaps
- incomplete information about patient status
- lack of information provided to the care team by physicians with respect to clinical management
Further review of CMPA cases identified system factors that may have hindered situational awareness. These included inadequate training or support of physicians and nurses, the use of outdated guidelines (e.g. nomenclature used to describe fetal status), the lack of a back-up system for emergencies, and issues with the functioning or availability of equipment or resources.
Issues with documentation were identified by peer experts in approximately one-quarter of the CMPA cases. Absent documentation was interpreted in some cases as evidence that the team was distracted at the time of the event. Clinicians often cited high volume or acuity of workload as reasons for their sparse or non-contemporaneous notes. However, the team’s ability to provide safe care was adversely affected in cases where important patient information was inadequate or not available in the health record for other care providers. Frequently, the lack of documentation made it difficult to determine the rationale for the clinical decision-making and impossible for the experts to support the care in question.
Improving situational awareness in labour and delivery
The following suggestions, based on peer expert opinions from CMPA cases, may help to strengthen individual and team situational awareness:
For front-line care providers
- Promote a culture of safety with open and respectful communication that encourages patients, families, and providers to speak up when they have concerns.
- Adopt strategies to identify and reduce errors in clinical decision-making (including those originating from cognitive biases) and the negative effects of stressors (e.g. fatigue, task-overload).
- Use standardized terminology when communicating patient status and when documenting this information in the health record.
- Hold periodic briefings or “huddles” to review patient needs and care plans with all staff in the unit.
- Review and celebrate “good catches” where effective teamwork and communication prevented potential harm.
For healthcare leaders
- Foster a culture of safety by providing multidisciplinary education to support teamwork, communication, and situational awareness.
- Use in situ simulation and drills to practise anticipating and rapidly responding to emergencies.
- Evaluate the care provided by the team by measuring processes and outcomes (e.g. trigger tool chart review); use the results to inform quality improvement, and to close the loop through education and feedback.
- Develop contingency plans for situations where additional resources might be required.
Dynamic conditions require situational awareness
When minutes count, patient safety depends on a highly reliable provider response. This requires that individuals and teams notice, understand, and think ahead, as well as adapt to dynamic conditions.6
Disclosure: The CMPA disclosed that the project in reference 1 of this article, "Situational Awareness and Patient Safety – A Short Primer," was funded by the Canadian Medical Protective Association Competitive Grant Program.
- Parush A, Campbell C, Hunter A, Ma C, Calder L, Worthington J, Abbott C, Frank J. Situational Awareness and Patient Safety - A Short Primer. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2011.
- Stanton NA, Chambers PRG, Piggott J. Situational awareness and safety. Safety Science. 2001;39:189-204.
- Edozien LC. Situational awareness and its application in the delivery suite. Obstet Gynecol. 2015;125:65-9.
- Legal, medical regulatory authority (College), and hospital cases closed between 2010 and 2014, involving a delivery that occurred between 2005 and 2014.
- 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.
- Rochlin GI. Safe operation as a social construct. Ergonomics. 1999;42:1549–60.