Best way to avoid a lawsuit? On L & D, you plan ahead



Labor and Delivery is a problematic specialty that requires a high degree of commitment and close teamwork. Too often, both of those variables are missing, with devastating effects upon both patient and physician.

Given the fact that there is approximately one birth an hour in most L & D rooms, it is easy to understand the challenges in coordinating an ad hoc team. Severely ill patients, in particular, require close coordination among the physicians in charge. The situation requires a high degree of commitment, a goal—like effective teamwork—not that easy to achieve.

The solution to this problem is to have an arrangement worked out and agreed upon beforehand. Such an agreement would require the attending physician to respond as delineated whenever he or she encounters an acute, sudden change in pregnancy that requires critical care, such as:

  • chest pain, tachypnea, or pulse oximetry 2
  • hypotension, sepsis, diabetic ketoacidosis, respiratory or neurologic emergency, need for cardiopulmonary resuscitation, pulmonary or amniotic embolism, or trauma
  • excessive blood loss
  • a category 2 or 3 tracing
  • risk of breech delivery or shoulder dystocia
  • cord prolapse
  • metabolic acidosis.

When the attending physician calls this protocol, or has a nurse or resident call it, he or she is immediately joined by two attending members. This team is fully committed to the patient from that moment on. Taking notes, both physicians go through an established and familiar checklist, which includes oxygen level, fluid assessment, measurement of vitals, measurement of blood gas, electrocardiogram, and appropriate labs. Should it be warranted, they will call for a rapid-response team, anesthesia, or other available equipment and assistance.

Because too many planes have been crashing on carriers and airfields, two air-traffic controllers are now required to be on deck to launch a plane or stop a landing. Why not have two attending physicians working together to prevent a catastrophic event or call in the rapid-response team? Residents are not all equal, and neither are attendings. A call for help takes too much thought, and so does committing to another attending. If everything is arranged beforehand, this hesitancy and doubt can be eliminated.

When the response to the protocol is complete, the checklist can then be used with facility until the patient is tucked in and labs are scheduled at 6-hour intervals.

Properly applied and administered, the jeopardy protocol should help us provide each patient with the best possible care.

Theodore M. Hale, MD, MA
Assistant Professor of Obstetrics and Gynecology
Weill Cornell University
New York City

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