Managing obstetric risk: Is your labor and delivery team ready?

Key Points

The primary goal of medical professionals is to provide patients with the best possible care and outcomes. In pursuit of this goal, progressive advances in medicine have made healthcare more complex, more dependent on technology, and increasingly reliant on multiple team members, which has greatly increased opportunities for error. As the ability to treat complex diseases has improved, the risk of quality failure has increased. Although the idea of keeping patients safe and providing them with the best outcomes is certainly not new, turning these ideas into practice has taken center stage in healthcare today. This article reviews the origins of the patient safety movement, details the current state of patient safety in obstetrics, and outlines 2 of the most serious threats to safe care, providing strategies to mitigate them.

The patient safety movement

The most fundamental principle guiding patient safety efforts is recognition of the ubiquity of human and system latencies that contribute to medical errors. By understanding that some errors are inevitable but most are preventable, patient safety efforts focus on human fallibility and seek to enhance communication, develop failsafe measures, and establish barriers that decrease the likelihood that an error will manifest itself at the bedside.

Acknowledging that medicine is similarly stressful, time constrained, and teamwork dependent, patient safety leaders have adapted many of the principles and techniques of aviation to the healthcare environment.¹ Over the last 10 years the patient safety movement has shown great progress, and improvements in safety have been documented in cardiology,² critical care,³ surgery,⁴ and anesthesia.⁵ However, patient safety initiatives in obstetrics lagged behind many other specialties, despite the fact that childbirth is one of the most common reasons for hospital admission in the United States, accounting for 4 million hospitalizations each year and ranking second only to cardiovascular disease.⁶ While good outcomes are anticipated in obstetrics, adverse events occur in up to 16% of deliveries in the US.^7-9 Anticipation of a favorable outcome, mostly among young women, and the fact that 2 patients-mother and child-can be affected make any adverse outcome particularly devastating and shocking. Despite this, few published models exist to guide providers in reducing obstetrical adverse outcomes and there is little agreement on standards for assessing rates of adverse events in perinatal care.

Lack of traction for safety initiatives in obstetrics is especially perplexing given that the discipline is considered to be in a chronic professional liability insurance crisis. Although ob/gyns represent only 5% of US physicians, they generate 15% of liability claims and 36% of total payments made by medical liability carriers.¹⁰ The average payment for a single obstetric liability claim ranges between $500,000 and $1.9 million.¹¹ Given that 90.5% of obstetricians have experienced at least 1 liability claim during their careers, with an average of 2.69 claims per physician, the liability crisis has a significant impact on the practice of obstetrics.¹² Concomitant to this crisis, obstetricians have changed their practice considerably, with 19.5% performing more cesarean deliveries, 19.5% eliminating trials of labor after prior cesarean delivery, 21.4% reducing their number of high-risk OB patients, 10.4% decreasing their number of deliveries, and 6.5% stopping practice altogether. The impact of these practice changes are so substantial that in 2004 the American College of Obstetricians and Gynecologists issued a "red alert" naming 23 states where the professional liability insurance crisis affected availability of obstetricians.¹³

As a result, instead of finding a means to deliver care more safely, many obstetricians have limited their practices. Avoidance of patients and procedures does not eliminate risk; however, it does exacerbate healthcare access and workforce gaps. The more appropriate approach to this crisis is to avert problems before they happen by addressing ubiquitous trouble spots in our practice, guided by the successes of other industries and medical disciplines. In our experience, 2 of the biggest barriers to safe obstetric care are suboptimal communication and use of powerful drugs such as oxytocin.