Reducing the legal risks of labor induction and augmentation
Specific tactics minimize the chance of adverse oxytocin-related outcomes—and a flurry of allegations
We also lack prospective studies demonstrating that intrauterine pressure catheterization can predict placental abruption. Placement of the device purely for this reason is not indicated.
Titration of oxytocin
No consensus on frequency or intensity of contractions
Criticism of the method of oxytocin titration is common in malpractice claims because no data satisfactorily define adequate frequency or intensity of contractions.
Nor do we have widely accepted terminology to describe uterine activity. For example, hyperstimulation is sometimes defined as increased frequency of contractions with an abnormal fetal heart rate tracing, and sometimes as increased frequency of contractions without a nonreassuring fetal heart rate. The same inconsistencies hold true for the terms “hypertonus,” “tetany,” “tachysystole,” and others.
“Adequate labor pattern” has been defined as 3 to 5 contractions in 10 minutes or 7 contractions in 15 minutes,7 even though these criteria are based on limited data. Although clinically adequate labor is defined by cervical dilatation and effacement with fetal descent, this definition frequently leaves us titrating oxytocin by “trial and error.” Fortunately, the half-life of oxytocin is short, and we can use fetal and uterine response to guide titration.
No definitive predictors of rupture, abruption, asphyxiation
When uterine rupture, placental abruption, and/or variant fetal heart patterns occur with hyperstimulation or elevated resting tone, the possibility of a cause-and-effect will be explored in legal claims. Although uterine rupture has been attributed to oxytocin in older, nonprospective, uncontrolled studies, more recent investigations8 failed to confirm this link.
The effect of uterine hyperstimulation on fetal oxygenation is even less well established. Contractions increase placental vascular resistance, which in turn decreases uteroplacental blood flow. This phenomenon has been demonstrated in studies utilizing Doppler velocimetry,9 radioangiography,10 and fetal pulse oximetry.11 However, none have been able to quantify, in millimeters of mercury, the intensity of uterine contractions or baseline tonus required to compromise fetal oxygenation.
Risk-reducing tactics
These strategies12 do not represent the standard of care, but may help reduce liability:
- Routinely assess fetal heart rate during examination of the laboring patient.
- Document EFM interpretation comprehensively. Include baseline, variability, accelerations, decelerations, and uterine activity, as well as overall impression.
- Date and time every entry.
- When notified of a finding, detail the notification, as well as the orders and plan of care communicated to the nurse.
- Develop a mechanism for documentation when you are located outside the hospital (eg, progress notes that are later posted in the chart).
- Use digital storage and retrieval with central monitoring of displays to allow physicians to observe EFM tracings via remote access.
- Use handheld PDA-type displays.
- Go to the bedside to evaluate a patient when nurses ask you to do so. Document date and time, and the fetal heart rate interpretation.
- Decrease or discontinue oxytocin when variant fetal heart rate patterns suggest decreased uteroplacental perfusion (FIGURE 1).
- Avoid further increases in oxytocin once adequate labor (progressive cervical change) is established.
- Consider decreasing oxytocin—or avoid further increases—when uterine contractions are more frequent than 5 in 10 minutes or 7 in 15 minutes (FIGURE 2).
- Use National Institute of Child Health and Human Development terminology in verbal communications with nurses and physicians (see the Web version of this article for a downloadable PDF file of this terminology).
Martin L. Gimovsky, MD
Program Director, Department of Obstetrics and Gynecology, Newark Beth Israel Medical Center, Newark, NJ
Clinical Professor of Obstetrics and Gynecology, Mount Sinai School of Medicine, New York City
As obstetricians, we are fortunate to participate in the most basic aspect of the human condition: the need to reproduce. Sometimes it is easy to overlook this fact, given the routine nature of many of our practices.
A case in point: oxytocin administration to induce or augment labor, an everyday occurrence in virtually all labor and delivery suites. Oxytocin is so ubiquitous, it can be easy to use it less than meticulously. Although the risks associated with its use are largely recognized, and the appropriate responses well known, a few points bear repeating.
Twin challenges: Protect and document
Safe and judicious use of oxytocin involves 2 challenges: minimizing medical risks to mother and fetus, and creating a supportive medical record. As in all aspects of medical care, we are required to know how to handle the clinical situation, and to document our skill, knowledge, and experience. Nowhere is this of greater concern than in the management of labor and delivery.
Here are 6 additional strategies for reducing legal risks of oxytocin use in labor.
1. Start with a written note
I suggest entering a written note into the record prior to administering oxytocin, outlining the reasoning behind the decision to proceed. Taking this pretreatment pause or “time out”—as the Joint Commission on Accreditation of Healthcare Organizations calls it—provides an opportunity to consider the risks, benefits, and alternatives of oxytocin use. This note should include the medical indication.
2. Conduct a comprehensive consent process
A passive signature on a general consent form is a minimalist way of demonstrating patient consent. By beginning the charting at the time of the consent discussion, you can demonstrate your consideration of the patient’s understanding and desires, not to mention your adherence to the highest standards of care.
Was an alternative approach possible? The patient should have the benefit of your opinion as well as a discussion of other reasonable strategies. Involving her in an active discussion is a fundamental component of informed consent—especially since improper consent is a frequent allegation in malpractice actions.
3. Describe both uterine and fetal responses
Because oxytocin directly affects uterine activity and indirectly affects placental perfusion, any chart notation needs to include references to both. For example, the comment that “contractions are every 2 minutes” requires the additional observation that the fetal heart rate tracing “is reassuring,”…“unchanged from earlier,”…or “demonstrates changes that are being evaluated.”
Whether a notation is made at the time of a routine labor check or when the physician is called to the bedside, comments on both uterine activity and fetal response are needed.
4. Discontinue oxytocin when the uterus overreacts
On occasion, excessive uterine activity may occur when oxytocin is first administered. Excessive uterine activity on a continuing basis can lead to fetal asphyxia. Although reducing the oxytocin dose will ultimately diminish uterine activity, I teach residents to discontinue oxytocin completely as soon as excessive uterine activity occurs.
Because this is a clinically important intervention, the medical record should be notated.
5. Adjust oxytocin to reflect changes in labor patterns
It makes good sense to avoid further oxytocin increases once the patient is in active labor (ie, progressive cervical change) and to decrease doses when contractions occur more frequently than every 2 minutes, even in the face of a reassuring fetal heart rate. This is not a situation in which, “if a little is good, a lot is better.”
6. Consider including a labor curve
Adding a labor curve or partograph to the chart can be a further safeguard, as it makes it easy to identify prolonged labors and potential complications in a timely manner.
All 6 strategies help demonstrate and preserve your hard work and concern for the patient. As always, adherence to principles of sound care and communication is the bedrock of successful obstetrics. There is no substitute.
The author reports no financial relationships relevant to this article.
