Reducing the legal risks of labor induction and augmentation
Specific tactics minimize the chance of adverse oxytocin-related outcomes—and a flurry of allegations
A 2005 Cochrane review4 of 18,561 births compared EFM with intermittent auscultation in labor and delivery and found fewer neonatal seizures in the EFM group but no differences in Apgar scores of less than 4 and 7, NICU admissions, perinatal deaths, or cerebral palsy.
“Default” intervals
Not only is the type of fetal monitoring important, but also how closely and how often the strip is evaluated. However, no studies have determined the optimal frequency of EFM interpretation during normal labors, let alone those induced or augmented with oxytocin. Furthermore, no single best methodology has been identified. Rather, the “default” timing of EFM interpretation has been loosely based on the historical practice of evaluating and documenting intermittent auscultation at 30-minute intervals during active labor and 15-minute intervals during the second stage for low-risk patients. For high-risk patients, the intervals have been every 15 minutes during the active phase and every 5 minutes during the second stage.
What will expert witnesses look for?
After adverse outcomes, the EFM tracing will be examined closely by “experts” looking for evidence that it contained abnormalities demonstrating fetal compromise or predicting the infant’s injury or death.
These experts also scrutinize the actions of physicians and nurses for appropriateness, timeliness, and effectiveness; the timing of the decision for expedited delivery; and the events occurring between that decision and the time of delivery or abdominal skin incision.
The monitor’s shortcomings
Many courts now require experts to base their opinions on reliable scientific studies; however, in malpractice claims involving EFM, expert interpretation often is based on the expert’s own personal or institutional experience or common practices rather than scientific evidence.
One of the most pervasive public misconceptions is that fetal monitoring can reliably detect when a fetus lacks sufficient oxygen, is experiencing a physiologically stressful labor that is depleting oxygen reserves, or is becoming asphyxiated. In reality, the positive predictive value (ability of the technology to identify the compromised fetus without including healthy fetuses) is very low: 0.14%. Thus, of 1,000 fetuses with nonreassuring tracings, only 1 or 2 are actually compromised.5 This may explain why providers and nurses are reluctant to deem all nonreassuring recordings as accurate.
The only thing EFM reliably identifies with a high degree of specificity is the oxygenated fetus that is not experiencing metabolic acidemia. Recordings with “nonreassuring” features are statistically unlikely to imply a diagnosis of fetal metabolic acidosis, hypoxemia, or stress or distress.
Should EFM precede oxytocin?
No minimal duration of monitoring prior to oxytocin administration has been consistently determined. Researchers do not even agree that initial monitoring of the fetus scheduled for induction has benefit.
This does not mean that oxytocin can be started without knowledge of the maternal and fetal condition—only that the best timing and methods of assessment prior to induction of labor are unknown.
What is “nonreassuring”?
Starting oxytocin in a woman with a “non-reassuring” tracing opens the OB to criticism. This is the most contentious aspect of medical and nursing management because we lack standardized definitions of “reassuring” and “nonreassuring.”
Nurses typically label a tracing nonreassuring based solely on decelerations or other variant patterns such as tachycardia. However, while a tracing’s individual characteristics may reflect a variety of etiologies (one of which is decreased uteroplacental perfusion), variability and/or accelerations signify an overall reassuring status, or fetal tolerance of labor.
Physicians generally examine the tracing in light of other clinical factors, such as labor progress, historical data, or parity—and also in light of any specific actions that have been taken and the expected time of their peak effect.
When to notify the OB
Another contentious issue in labor induction is exactly when nurses should notify the physician of a nonreassuring fetal heart rate. Unfortunately, there is no consensus about this question, either; again, most EFM tracings requiring nursing intervention exhibit an overall reassuring status.
Because evaluation of nonreassuring findings may take several minutes, nurses usually notify the physician when their assessment is complete. If the worrisome tracing resolves after intervention, a nurse may appropriately postpone notification until the next opportunity for communication with the physician.
Uterine monitoring
Can monitoring predict rupture?
In cases involving uterine rupture and/or placental abruption, experts may allege that the event could have been predicted with an intrauterine pressure catheter. However, in a study of “controlled” uterine rupture (recording of intrauterine pressure before and during uterine incision at the time of cesarean section), Devoe et al6 found no real differences in contraction frequency or duration, peak contraction pressures, or uterine resting tone prior to and after uterine “rupture” (incision).
