The following risk management suggestions were developed in order to assist the OB/GYN practitioner in making judgments about the management of patients, particularly in areas where there is significant claims experience. All practitioners know that individual and widely varying circumstances determine the nature of decisions related to the care of a particular patient. Individual circumstances, philosophies, styles of practice, individual skills with certain techniques and events with patients do widely vary.

These suggestions are not to be construed as standards of care; they are simply tools at your disposal meant to aid you in making decisions, help you avoid risk management pitfalls and help you explain decisions if an outcome triggers a challenge. It is worth noting, as mentioned in a recent article by Dr. Blickstein, "a much higher degree of certainty is necessary for scientific evidence than for evidence presented in a court case - therefore it is possible that courts may accept findings that are scientifically flawed." This statement is a truism that runs counter to the thinking of most doctors. It follows that the importance of documentation of thinking, plans and actions cannot be overemphasized; to do so adds tremendous weight to a doctor's defense. Good (objective, pertinent and not self-serving) documentation will often make the difference between an attorney taking or rejecting a case and thus potentially save the doctor needless anxiety, time, interruption of life and hassle. Forthright and sincere communication with the patient can accomplish the same.

Fetal Monitoring and Related Delivery Decisions

Once you are aware a non-reassuring pattern has developed, ask for the usual conservative measures, such as increasing IV fluids, positional changes, and discontinue or adjust until the tracing becomes reassuring. Document these measures in the progress notes or ask for their entry into the nursing records. Question interpretations where non-standard jargon is used. For example, the term "late variables" is not standard terminology.

• When a nurse is giving a report, listen to the content and style. Ask for direct and clear communication from the nursing staff.
  
  
• Are there unspoken expectations? When in doubt, personally investigate and document.
  
  
• Give the OR and supportive staff heads-up if C/S is contemplated. If decision is made to perform C/S, make a written note of the time when it is declared urgent and supervise the timely transfer of the patient to the OR and establishment of anesthesia. Be vocal about avoiding any significant delay.
  
  
• When an antepartum NST is non-reactive or equivocal, maintain a system whereby repeat testing or additional testing is done in a timely manner. Example: reactive when two accelerations 15 bpm over baseline within 20 minutes.
  
  
• Combination of non-reassuring tracing, attempt at vacuum delivery and perceived delay in cesarean section troublesome. If vacuum attempt is judged appropriate, take measures to alert the OR and expedite transfer in case a cesarean decision is made.
  
  
• Involve the patient in the decision-making regarding their treatment.

Page 1: Fetal Monitoring and Related Delivery Decisions
Page 2: Important Facts about Cerebral Palsy
Page 3: Oxytocin, History of Cesarean Section/VBAC, Group B Streptococci Carriers
Page 4: Shoulder Dystocia, Placental Pathology, Documentation & Records