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Perinatal Litigation and Related Nursing Issues
Clin Perinatol 32 (2005) 277 – 290
Perinatal Litigation and Related Nursing Issues Patricia A. Dunn, PhD, RNCa,*, Mary Lou Gies, MSN, RNb, Mary Anne Peters, DNSc, RNb a
School of Nursing, Holy Family University, 9701 Frankford Avenue, Philadelphia, PA 19114, USA b LaSalle University School of Nursing, 1900 West Olney Avenue, Philadelphia, PA 19141, USA
General considerations There is an increasing perception of the fetus as a patient; this is accompanied by an enhanced emotional and financial investment of the parents and the medical practitioners [1]. Families have high expectations of health care providers and expect optimal outcomes. Adverse outcomes commonly result in claims of medical malpractice. Traditionally, nurses have not been named individually as defendants in malpractice cases. Increasingly, nurses are named as primary and secondary defendants in these cases. Perinatal nurses need to be cognizant of the legal environment and how to protect themselves against legal action. Babies who have severe neurologic deficits may live for many decades; their life-long care can be costly. Most physician insurance policies, along with state catastrophic funds, pay a maximum of only $1.2 million. This may be inadequate to meet the needs of a severely disabled child. Larger amounts can be reaped if a nurse is found negligent. This is because the nurse is usually an employee of the hospital or institution; this increases the available insurance coverage. This doctrine of ‘‘respondent superior’’ provides that vicarious liability may be imposed upon an employer for the wrongful acts of an employee where the employee’s actions are within the scope of employment. Furthermore, an employer as a corporation also may be liable [2]. For example, a hospital may be
* Corresponding author. E-mail addresses: [email protected] or [email protected] (P.A. Dunn). 0095-5108/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.clp.2004.11.001 perinatology.theclinics.com
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found liable for improper policies and procedures. By including doctors, nurses, and hospitals as defendants, settlements and trial verdicts can generate much money for the plaintiff. It is not uncommon for settlements for infants who are severely neurologically compromised to be made for millions of dollars; some recent trial verdicts have exceeded $100 million. The National Practitioner Data Bank (NPDB) was created by federal law and was operational by 1990. If malpractice payments, including judgments, arbitration decisions, and out-of-court settlements, are made by or for the nurse, the payment must be reported to NPDB by the hospital, employer, state licensing board, or insurance company [3]. Often, physicians avoid settling even small claims to prevent their names from appearing in the NPDB. This increases the likelihood that nurses, and the hospital as a corporation, will be prosecuted aggressively in a malpractice suit [4], especially in a case where monetary needs are high. Perinatal nurses need to have knowledge of the elements of malpractice and be aware of potential ramifications and methods to decrease vulnerability.
Elements of a malpractice suit A standard of care is an external code of behavior or expected performance for the professional. Legally, a standard of care holds a health care professional to the duty of acting how a reasonable and prudent person, possessing the same or similar skills or knowledge, would act under similar circumstances; this is the underlying principle used to establish practice standards. Nurses’ actions are measured against the standard of care similar to the caregivers’ community. Nursing standards often are different from medical standards. Standards of care, guidelines, and codes of ethics may be defined by the American Nurses Association, the State Practice Act, and specialty organizations, such as the Association of Women’s Health, Obstetrical, and Neonatal Nurses and the National Association of Neonatal Nurses [5,6]. To be held liable in a medical malpractice case, a nurse must have breached a standard of care that caused, or significantly contributed to, the plaintiff’s injury. Malpractice is defined as negligence in a professional act and occurs when care falls below the standard of care. To prove that malpractice or negligence occurred, four elements must be established: duty, breach of duty, causation, and damages. Liability is the responsibility for acts of negligence [5]. Malpractice may be due to lack of training; failure to follow a policy; or other factors (eg, stress, fatigue). Regardless of the underlying reason, the medical malpractice system holds the nurse accountable for negligent acts. The nurse has a responsibility to implement and maintain standards of professional nursing practice [5,7,8]. The burden of proof of malpractice falls on the plaintiff. The plaintiff’s attorney must use hired expert witnesses to offer opinions that the standard of care was not met. Defense attorneys will retain similar experts to defend physician and nursing practice or to diffuse the plaintiff’s experts’ claims. The
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physician and nurse defendants should use different expert witnesses—the nurse should not assume that the physician will share the same point of view [9,10]. Nurses will be defended best with nurse experts who have expertise in the related field. Most states, however, have permitted physicians to testify as to nursing standards of care despite the fact that, unless the physician has practiced as a nurse, the physician only can present what he or she has witnessed or opines what the nurse should have done. Conversely, nursing experts consider the complex and separate nursing regulatory and licensing issues, use of the nursing process and critical thinking, Nurse Practice Acts, state hospital codes, standards and guidelines from nursing organizations, and additional nursingspecific issues. Most physicians are inexperienced with these issues. The American Association of Nurse Attorneys (TAANA) believes that a nurse is the only expert who is competent to testify as to the standard of care for nursing practice. The profession of nursing, although closely related to the practice of medicine, is distinct with its own educational and licensing requirements, areas of specialization, code of ethics, standards and guidelines for care, models and theories, and expectations from society. TAANA submitted an Amicus brief to the Illinois Supreme Court regarding the above to support that only a nurse expert meets requirements to testify about nursing care, and the Illinois Supreme Court held that only a nurse is qualified to offer expert evidence as to the standard of care for nurses (Sullivan v Edward Hospital, No. 95409, 2004 WL 228,956 (Ill. February 5, 2004) [11]. Malpractice suits have a time limit—termed the ‘‘statute of limitations’’— within which the suit can be filed. The statute of limitations is determined by state laws and generally is 2 to 3 years from the date of the injury or from the date on which the injury was discovered [12]. In the case of minors, however, the statute of limitations commonly is added to the age of majority; this allows for filing of suits up until the child reaches the age 18 or 21. In certain cases with extreme brain injury, courts have ruled that the age of majority is never reached and there is no statute of limitations. After a case is filed, the doctor or nurse should not discus the case with colleagues or friends. Any conversation about the case outside of a peer-review situation or with the defendant’s attorney is discoverable. Ultimately, the nurse who provided care most likely will be deposed. The nurse will be asked about what is documented on the record and also about what he or she recalls independently about the case. The nurse will be asked if he or she discussed the case or care with anyone else, including the patient and family. If so, the nurse will be asked what was said. A deposition is taken under oath and must be truthful. The deposition testimony can be read in the courtroom and compared with the courtroom answers to the jury. The trial testimony can deviate little, if any, from the nurse’s earlier deposition testimony. After the facts are gathered, the case may be settled out of court, go to arbitration or mediation, or go to a trial. If a jury finds that practitioners were negligent and the negligence caused injury, percentages of negligence are decided and a monetary settlement is awarded. Hypothetically, if $10 million is awarded
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and the obstetrician is found 90% negligent and is insured for $1 million, the policy will pay the $1 million. If the nurse is found to be only 10% responsible, the hospital may have to pay the remaining $9 million. Perinatal nurses need to be cognizant of common areas of litigation and strategies to reduce their risk for liability when caring for women and newborns. Although legal actions against nurses are escalating, providing safe and high quality care is the best preventive strategy. In the following section, we address some of the most common allegations against perinatal nurses and provide recommendations for safe patient care and protection for the perinatal nurse.
Common allegations in perinatal nursing and risk reduction Since July 2001, Joint Commission on Accreditation of Healthcare Organizations has required that patients be informed if an error or unexpected outcome occurred [13]. Although this may have not led to significantly more medical malpractice lawsuits, there is evidence that the settlements and jury verdicts have increased in amount substantially. The Chicago Lawyer 2004 Settlement Survey found that birth-trauma cases led to 5 of the 10 largest settlements in Illinois in 2003, including the largest settlement of the year—a $35 million agreement. Although these types of cases accounted for only 15% of the reported 97 total settlements, the pay-outs in birth-trauma cases accounted for 25.5% ($144.7 million of $567.57 million) of total settlement funds [14]. Dr. John C. Nelson, a practicing obstetrician/gynecologist who served as president of the American Medical Association, concluded that the system has become more confrontational and adversarial, yet it has not identified the bad doctors or improved the quality of health care [14]. The most common types of lawsuits in which perinatal nurses have been named include the catastrophically brain-injured infant, nonbrain injury obstetric injuries, brachial plexus injury, wrongful fetal or neonatal death, injury to the mother, and wrongful maternal death. There have been several key, repetitive allegations made against nurses that have been associated with the above injuries. Alleged nursing acts of negligence that could result in a malpractice case as well proactive strategies for the nurse to fulfill the nursing standard of care will be addressed.
Failure to assess Goals of Healthy People 2010 include reducing fetal and perinatal deaths from 6.8 and 7.3/1000, respectively, in 1997 to 4.1 and 4.5/1000 in 2010. Another goal is to reduce the maternal death rate from 9.9 per 100,000 to 3.2 per 100,000 [15]. To achieve these goals, regionalized perinatal care is coordinated between basic, specialty, and subspecialty care units and interhospital transfer is encouraged when appropriate [16]. Claims have been made that if a nurse properly assesses a
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patient on admission, a high-risk status may be identified and an indication for transfer to a hospital that can provide a higher level of care may be recognized. The attending physician—not the nursing staff—has the ultimate responsibility for initiating a patient transfer; however, nurses have involvement in the process and share accountability with the physician [16]. On admission or presentation, the professional nurse is responsible for assessing patients in a time frame to meet the general needs of their patient population. Thus, if a prolonged period of time occurs between presentation for care and actual evaluation, the nurse may be deemed liable for complications that could have been prevented if they had been identified and corrected earlier. The nurse needs to take an adequate history, assess the condition of the women and fetus, and recognize findings that require immediate action. The nurse is responsible for notifying the certified nurse midwife or physician in a timely and effective manner. Various events during labor or in the postpartum period may have an influence on maternal vital signs. The perinatal nurse needs to identify significant changes in maternal vital signs and recognize symptoms of maternal complications that may occur (eg, a mother’s blood pressure may be lowered by epidural analgesia, medications, or hemorrhage). The nurse needs to be able to distinguish signs that may coexist that are alarming. To decrease the risk of liability, the perinatal nurse should assess the patient according to recommended protocols. Assessments and communication with the patient’s physician should be documented clearly.
Failure to document adequately Legally, the medical record is the single, contemporaneous valid record of events. The plaintiff’s attorney will use the adage ‘‘if you didn’t document it, you didn’t do it.’’ During a deposition or trial a nurse might have the opportunity to present additional information, although a jury may not consider undocumented evidence as strongly as contemporaneous documentation in the medical record. The record should provide evidence that the nurse’s actions were consistent with the standards of nursing practice. A plaintiff’s attorney may argue that the standard of care was breached by the nurse who did not document care. Because many fetal and maternal complications are not anticipated, comprehensive documentation of assessments and care are imperative. Nurses should focus on objective documentation and avoid speculative nurses’ notes. Nurses should report their assessment findings and avoid assumptions about the source of the injury in charting, even if told so by another practitioner [17]. For example, it is inappropriate to document that a neonate has perinatal asphyxia. Documentation of the patient’s status, assessments, care rendered, physician notification, and response is expected. The nursing process and critical thinking should be evident in the nurses’ notes or other documentation. Many hospitals have exchanged nursing care plans for clinical practice guidelines that may be individualized for the particular patient. Such clinical practice guidelines should be evidence-based [18]. In patient care, the nurse needs to be familiar with,
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and conform to, the contents of the standardized nursing care plans or clinical practice guidelines. Sometimes, patient care becomes such a high priority that documentation must suffer. The nurse should document retrospectively, indicating that the note is a retrospective note or late entry. Additionally, some institutions use documentation by exception or flowsheet charting. These methods may leave the nurse vulnerable because the nurse is required to use more judgment about what is documented. Complete documentation may protect the nurse who may not be able to recall the details or specifics of the case at a later time.
Failure to perform appropriate telephone triage The labor and delivery nurse is not the mother’s physician nor midwife and should not accept calls for triage regarding maternal–fetal status. The physician or midwife should take these calls or the patient should be instructed to come in for evaluation [19]. If, however, a nurse works for an institution that does accept telephone triage or questions, written protocols and mechanisms for physician or midwife follow-up should be in place. Documentation of such a call should be part of the patient’s records.
Failure to interpret fetal monitoring properly Common areas of litigation regarding electronic fetal monitoring tracings include the failure to identify, treat, document and report a nonreassuring fetal heart rate (FHR). Nurses are obligated to have the knowledge and expertise to provide fetal assessment and interpret fetal monitoring tracings accurately, provide appropriate independent nursing interventions, and ensure appropriate assessment and care [19]. Interdisciplinary policies and procedures of an institution should clarify competencies and provide guidelines for assessment and documentation. Methods of intrauterine resuscitation should be incorporated into these documents. Joint in-service education sessions for physicians and nurses on fetal assessment help to assure a standardized knowledge base for the medical and nursing team. According to current guidelines, the method of fetal surveillance in labor may vary, depending on the risk assessment at admission and the preference of the patient and providers. Initial assessment of fetal status is performed on admission. If no risk factors are present at the time of admission, the FHR may be auscultated every 30 minutes in the active phase of the first stage of labor and every 15 minutes in the second stage of labor. If electronic fetal monitoring is used, assessment intervals should be the same. For patients who have risk factors, the FHR should be assessed every 15 minutes in the active phase of the first
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stage of labor and every 5 minutes in the second stage of labor. When electronic fetal monitoring is used, documentation should reflect evaluation of the tracing at the recommended intervals. All providers should use accepted terminology (eg, accelerations, early decelerations, variable decelerations, late decelerations, variability) [16]. Printing and archiving FHR tracings provides valuable information for future reference. The electronic fetal monitor strip needs to be saved as part of the mother’s medical record for as long as a malpractice suit can be filed. Electronic tracings are being filed and accepted with the records into court.
Failure to possess proper knowledge and competency A perinatal nurse is required to be knowledgeable and competent in his or her field of practice. Nurses share the responsibility with their institutions in evaluating their competency and seeking resources to keep current. Competencybased orientations assure institutions that nurses are able to use equipment and provide care for patients in various situations. Lack of current education in the areas of fetal heart rate interpretation [20], in particular, as well as in neonatal resuscitation, are common areas of litigation. Continuing education and certifications help to maintain competency. Standards of care of professional organizations and regulatory agencies should be maintained and available at health care institutions and incorporated into policies. By meeting the standards of care and maintaining competency, the nurse reduces the risk of liability.
Failure to initiate the chain of command The chain of command concept should be familiar to all nurses who provide patient care in any setting. The chain of command is a specific course of action that involves administrative and clinical lines of authority that are established to ensure effective conflict resolution in patient care situations. This mostly is applicable in emergency situations. The concept of the ‘‘captain of the ship’’ no longer relieves the nurse from the responsibility of ensuring adequate physician response. Nurses have a duty to be a patient advocate through the organizational chain of command when they know or believe that the physician is unresponsive to concerns about the patient’s condition, is making inappropriate patient care decisions, or if a true conflict exists [21,22]. The nurse must have actual knowledge of incorrect physician performance. Examples of when to initiate the chain of command are if the physician has alcohol on his/her breath or if there is a clear disagreement about the presence of a nonreassuring electronic fetal monitoring strip. The chain of command would not be initiated when the physician is in the process of delivering a baby and the nurse expects an imminent delivery.
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Improper use of agents for induction of labor Sometimes, it is claimed that the nurse improperly administered misoprostol (Cytotec) or oxytocin (Pitocin) or permitted the physician or nurse midwife to do so. Cytotec is a synthetic prostaglandin E1 analog that originally was used as a gastrointestinal medication; it is used to ripen the cervix and for induction of labor. Uterine hyperstimulation and rupture can result. Case reports of rupture of an unscarred uterus exist [23]. Nurses should follow policies for administration that also delineate fetal and uterine monitoring. Cytotec should not be given more often than every 3 to 6 hours (up to 4 dosages in 24 hours) or to a woman who has a scarred uterus. Oxytocin should not be administered simultaneously. Documentation of times of administration are important. Improper administration of oxytocin may result in uterine hyperstimulation with or without a nonreassuring FHR pattern. Hyperstimulation of the uterus may, or may not, be dose-related [18,24]. There are various regimens for the administration of oxytocin. The nurse needs to assess the electronic fetal monitor strip carefully; if hyperstimulation occurs, the oxytocin should be decreased. If a nonreassuring FHR pattern accompanies the hyperstimulation, appropriate measures should be undertaken.
Improper management of shoulder dystocia Cases of shoulder dystocia injuries sometimes are based upon a failure to diagnose and predict the problem accurately [19], although these are not within the scope of nursing practice. Once a shoulder dystocia is diagnosed, prompt action is necessary to decrease fetal hypoxia. It is essential that the nurse, under the direction of the physician, avoid fundal pressure or cease fundal pressure after the shoulder dystocia has been identified. The McRoberts maneuver, followed by suprapubic pressure may be indicated. Other maneuvers fall under the scope of the physician or midwife. If delivery has been delayed for a significant amount of time, a depressed neonate may result and resuscitation needs can be anticipated.
Failure to begin a Cesarean section in a timely manner Current guidelines direct that institutions are able to begin an emergency Cesarean section within 30 minutes of the decision to perform one. The prudent nurse clarifies the emergent or nonemergent nature of the Cesarean section with the physician and documents the plan and time in the patient record. All personnel who are needed should be mobilized promptly according to the institutional policy. Although the primary responsibility for positioning anesthetized patients resides with the anesthesiologist, the nurse may share this responsibility to ensure that uterine displacement is maintained and that positioning to prevent nerve injury is accomplished. According to the Guidelines for Perinatal Care,
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subspecialty hospitals should have in-house obstetric and anesthesia coverage 24 hours per day. Fetal surveillance should continue until the sterile abdominal preparation is begun unless an internal fetal scalp electrode was used. An internal monitor should be left in place until the abdominal preparation is completed [16].
Failure to obtain informed consent Patients may claim that they were not informed of a procedure or potential complications. In many situations in which medical care or treatment is provided to an individual, medical professionals are required to obtain the patient’s ‘‘informed consent.’’ Although the specific definition of informed consent varies from state to state, informed consent requires that a medical provider tell a patient all of the potential benefits, risks, and alternatives that are involved in any surgical procedure, medical procedure, or other course of treatment, and must obtain the patient’s consent to proceed. It is the role of the physician—rather than a hospital representative, nurse, or other related health care professional—to speak to patients about informed consent. If this duty is breached and injuries result, the patient may have a legal claim for damages. Occasionally, the failure to obtain informed consent is a form of medical negligence and may give rise to a cause of action for battery. In certain situations, informed consent is an absolute necessity. For example, in any medical trials or experiments, informed consent must be obtained from any human participant or subject. Informed consent is not required for situations that involve routine medical procedures (eg, phlebotomy) or if the patient is unconscious and unable to communicate [25]. A mentally disabled person may have an appointed guardian who is authorized to make medical decisions and give informed consent for that individual. Some states allow young adults who are younger than 18 years of age to give their own informed consent for treatments that are related to pregnancy, substance abuse, mental health, and sexual activity. In most situations, parents can give informed consent for treatment of their minor children. The perinatal nurse needs to be aware of the individual requirements regarding informed consent and ensure that a valid consent is on the chart for elective or experimental procedures. If present when the informed consent is obtained, the nurse should document the process and the patient’s understanding. If a nurse witnesses an informed consent, the nurse is only witnessing the signature.
Inadequate staffing or improper delegation A nurse manager may be named as a defendant in a lawsuit, even if he or she had no direct patient care involvement but is involved in staffing and workload decisions. Several studies demonstrated that nursing workload affects the quality of patient care and safety. Increasing the nurse’s workload affects the
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process of care, including the ability of the nurse to monitor patients safely and complete all related nursing tasks [26]. A plaintiff’s attorney may question a nurse in such a manner that the nurse agrees that the unit was extremely busy or that the nurse felt overworked. The next question usually is related to what the nurse did about this, if anything. If a unit is extremely busy, the nurse has the duty to discuss the assignment with the charge nurse and go up the chain of command with his or her concerns, if necessary. Because of reduced staffing, nurses are finding it necessary to delegate some of the responsibilities of patient care to licensed practical nurses, nurse externs, and nurses aids. When entrusting care to other health care providers, nurses have an obligation to delegate according to the state nurse practice act as outlined by the State Board of Nursing [27].The registered nurse who makes the assignment has the accountability for it. To decrease liability when delegating patient care, the nurse manager must consider the stability of the patient, staff competencies, and availability and accessibility of resources [28].
Failure to provide adequate neonatal resuscitation Approximately 1% of all newborns requires resuscitation efforts to survive and to make the transition from intra- to extrauterine life. Another 10% of newborns, although not needing a full resuscitation effort, will require some type of support to make a successful transition to extrauterine life [29]. If the first few minutes of life are not handled competently, these fragile infants may face a lifetime of consequences. Reviews of litigated cases identified that the most serious errors that occur during neonatal resuscitation are failure to anticipate the arrest; failure to have appropriate personnel available; failure to have necessary equipment available; and performance of delayed, inadequate, or improper resuscitation [19,30]. To prevent these errors from occurring, perinatal nurses must complete a thorough history and physical examination on each newly admitted patient with the intent of identifying high-risk conditions that might affect the neonate. Careful monitoring of the maternal condition during labor also will enable perinatal nurses to identify changes in maternal-fetal status. This allows the nurse to anticipate the needs of the neonate and notify the necessary personnel to attend the delivery. At delivery, routine assessment and neonatal care should include resuscitation in accordance with the American Heart Association and the American Academy of Pediatrics Neonatal Resuscitation Program. In addition, one person at each delivery should be responsible to care only for the neonate. Every team of health care providers at a delivery should possess at least one individual who has the skills to initiate and perform a complete resuscitation. Resuscitation must be initiated without delay; all equipment and supplies that are required must be located conveniently for use during the anticipated resuscitation [16]. A complete neonatal resuscitation should be well-documented. A standardized neonatal resuscitation form provides a quick and efficient method for document-
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ing minute by minute changes in condition of the neonate and the corresponding medical response. Methods of decreasing liability include mock neonatal resuscitation practice sessions and regular certification and recertification in neonatal resuscitation.
Failure to treat neonatal hypoglycemia Hypoglycemia is a common problem that is experienced by neonates in the postpartum period. Neonates who experience protracted periods of untreated hypoglycemia can develop serious long-term neurologic complications, such as mental retardation and learning disabilities [31,32]. Failure to monitor for hypoglycemia in the high-risk neonate or failure to recognize the signs of hypoglycemia in any neonate are two common malpractice claims against perinatal nurses. Term, asymptomatic healthy infants do not need routine monitoring of blood glucose levels during the immediate postpartum period; however, neonates who are at risk for hypoglycemia need to be evaluated, even if asymptomatic. Many factors can affect the neonate’s glucose metabolism; it is essential for the perinatal nurse to be aware of maternal and neonatal risk factors. All infants who are at risk must be screened in a timely fashion. Delays in screening may lead to neonatal injury that is related to prolonged hypoglycemia. In addition, all symptomatic infants must be screened and treated promptly. Usually, the perinatal nurse is responsible for monitoring blood glucose levels in the neonate. It is essential that institutional policies for screening be followed and results of screening blood glucose assessments and evaluations of infant condition be communicated in a rapid fashion to the neonatal nurse practitioner or physician. Although controversy continues as to the definition of neonatal hypoglycemia and the determination of an absolute value at which injury occurs, there is no question that prolonged exposure to hypoglycemia can lead to neonatal injury.
Failure to treat for neonatal group B streptococcus sepsis Despite the publication of treatment guidelines by the Centers for Disease Control in 1996 and 2002, group B streptococcus (GBS) remains a common cause of neonatal infection. Early-onset GBS disease typically is identified within the first 24 hours of life. It is particularly difficult to diagnose GBS sepsis during the neonatal period because neonates often display subtle signs or changes in behavior that may have many causes [33]. The best practice for the perinatal nurse is to consider any infant who is not behaving normally as potentially septic. Nurses who care for newborns should obtain a detailed history from the nurse who cared for the mother during the intrapartum period. That history should include GBS status of the mother and any other information that might indicate
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increased risk for sepsis. Double checking the obstetric record with a verbal report provides the nurse with more comprehensive information about the condition of the mother and the newborn. All neonates should be assessed regularly during the first 24 hours of life for any behaviors that might indicate the development of sepsis. Low-risk neonates and neonates who are at risk for the development of sepsis must be monitored. If clinical signs of early-onset sepsis are identified, a full diagnostic evaluation is warranted [34]. Careful documentation of all findings and timely communication of findings to medical care providers are essential to reduce neonatal injury. The perinatal nurse can reduce liability by observing carefully any neonate that displays subtle signs, changes, feeds poorly, or has temperature instability. The nurse needs to be vigilant about documenting and communicating all significantly abnormal findings. Delays in treatment can lead to fulminant disease and possible death.
Summary Obstetric and neonatal nurses are expected to provide an abundance of guidance, support, monitoring, and education to women during and after delivery. Nurses should adhere to standards of practice and provide safety for the mother and fetus or neonate by sometimes ensuring that others are practicing according to the standards of care. Perinatal nurses also are responsible for providing routine assessments and initiating and performing emergency interventions. This includes recognition of the symptoms of complications in the mother and the neonate, resuscitation, and activation of the emergency system. Although the perinatal nurse continues to be at risk for malpractice vulnerability, risk reduction techniques are available to them.
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[31] Verklan MT. Malpractice and the neonatal intensive-care nurse. J Obstet Gynecol Neonatal Nurs 2004;33:116 – 23. [32] Johnson TS. Hypoglycemia and the full-term newborn: how well does birth weight for gestational age predict risk? J Obstet Gynecol Neonatal Nurs 2003;32:48 – 57. [33] Schrag S, Gorwitz R, Fultz-Butts K, et al. Prevention of perinatal group B streptococcus disease: revised guidelines from the CDC. MMWR 2002;51(RR11):1 – 22. [34] Morbidity and Mortality Weekly Report. Prevention of perinatal group b streptococcal disease: Revised Guidelines from CDC. Available at: http://www.cdc.gov/mmwr/PDF/rr/rr5111.PDF. Accessed October 20, 2004.
Perinatal Litigation and Related Nursing Issues Patricia A. Dunn, PhD, RNCa,*, Mary Lou Gies, MSN, RNb, Mary Anne Peters, DNSc, RNb a
School of Nursing, Holy Family University, 9701 Frankford Avenue, Philadelphia, PA 19114, USA b LaSalle University School of Nursing, 1900 West Olney Avenue, Philadelphia, PA 19141, USA
General considerations There is an increasing perception of the fetus as a patient; this is accompanied by an enhanced emotional and financial investment of the parents and the medical practitioners [1]. Families have high expectations of health care providers and expect optimal outcomes. Adverse outcomes commonly result in claims of medical malpractice. Traditionally, nurses have not been named individually as defendants in malpractice cases. Increasingly, nurses are named as primary and secondary defendants in these cases. Perinatal nurses need to be cognizant of the legal environment and how to protect themselves against legal action. Babies who have severe neurologic deficits may live for many decades; their life-long care can be costly. Most physician insurance policies, along with state catastrophic funds, pay a maximum of only $1.2 million. This may be inadequate to meet the needs of a severely disabled child. Larger amounts can be reaped if a nurse is found negligent. This is because the nurse is usually an employee of the hospital or institution; this increases the available insurance coverage. This doctrine of ‘‘respondent superior’’ provides that vicarious liability may be imposed upon an employer for the wrongful acts of an employee where the employee’s actions are within the scope of employment. Furthermore, an employer as a corporation also may be liable [2]. For example, a hospital may be
* Corresponding author. E-mail addresses: [email protected] or [email protected] (P.A. Dunn). 0095-5108/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.clp.2004.11.001 perinatology.theclinics.com
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found liable for improper policies and procedures. By including doctors, nurses, and hospitals as defendants, settlements and trial verdicts can generate much money for the plaintiff. It is not uncommon for settlements for infants who are severely neurologically compromised to be made for millions of dollars; some recent trial verdicts have exceeded $100 million. The National Practitioner Data Bank (NPDB) was created by federal law and was operational by 1990. If malpractice payments, including judgments, arbitration decisions, and out-of-court settlements, are made by or for the nurse, the payment must be reported to NPDB by the hospital, employer, state licensing board, or insurance company [3]. Often, physicians avoid settling even small claims to prevent their names from appearing in the NPDB. This increases the likelihood that nurses, and the hospital as a corporation, will be prosecuted aggressively in a malpractice suit [4], especially in a case where monetary needs are high. Perinatal nurses need to have knowledge of the elements of malpractice and be aware of potential ramifications and methods to decrease vulnerability.
Elements of a malpractice suit A standard of care is an external code of behavior or expected performance for the professional. Legally, a standard of care holds a health care professional to the duty of acting how a reasonable and prudent person, possessing the same or similar skills or knowledge, would act under similar circumstances; this is the underlying principle used to establish practice standards. Nurses’ actions are measured against the standard of care similar to the caregivers’ community. Nursing standards often are different from medical standards. Standards of care, guidelines, and codes of ethics may be defined by the American Nurses Association, the State Practice Act, and specialty organizations, such as the Association of Women’s Health, Obstetrical, and Neonatal Nurses and the National Association of Neonatal Nurses [5,6]. To be held liable in a medical malpractice case, a nurse must have breached a standard of care that caused, or significantly contributed to, the plaintiff’s injury. Malpractice is defined as negligence in a professional act and occurs when care falls below the standard of care. To prove that malpractice or negligence occurred, four elements must be established: duty, breach of duty, causation, and damages. Liability is the responsibility for acts of negligence [5]. Malpractice may be due to lack of training; failure to follow a policy; or other factors (eg, stress, fatigue). Regardless of the underlying reason, the medical malpractice system holds the nurse accountable for negligent acts. The nurse has a responsibility to implement and maintain standards of professional nursing practice [5,7,8]. The burden of proof of malpractice falls on the plaintiff. The plaintiff’s attorney must use hired expert witnesses to offer opinions that the standard of care was not met. Defense attorneys will retain similar experts to defend physician and nursing practice or to diffuse the plaintiff’s experts’ claims. The
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physician and nurse defendants should use different expert witnesses—the nurse should not assume that the physician will share the same point of view [9,10]. Nurses will be defended best with nurse experts who have expertise in the related field. Most states, however, have permitted physicians to testify as to nursing standards of care despite the fact that, unless the physician has practiced as a nurse, the physician only can present what he or she has witnessed or opines what the nurse should have done. Conversely, nursing experts consider the complex and separate nursing regulatory and licensing issues, use of the nursing process and critical thinking, Nurse Practice Acts, state hospital codes, standards and guidelines from nursing organizations, and additional nursingspecific issues. Most physicians are inexperienced with these issues. The American Association of Nurse Attorneys (TAANA) believes that a nurse is the only expert who is competent to testify as to the standard of care for nursing practice. The profession of nursing, although closely related to the practice of medicine, is distinct with its own educational and licensing requirements, areas of specialization, code of ethics, standards and guidelines for care, models and theories, and expectations from society. TAANA submitted an Amicus brief to the Illinois Supreme Court regarding the above to support that only a nurse expert meets requirements to testify about nursing care, and the Illinois Supreme Court held that only a nurse is qualified to offer expert evidence as to the standard of care for nurses (Sullivan v Edward Hospital, No. 95409, 2004 WL 228,956 (Ill. February 5, 2004) [11]. Malpractice suits have a time limit—termed the ‘‘statute of limitations’’— within which the suit can be filed. The statute of limitations is determined by state laws and generally is 2 to 3 years from the date of the injury or from the date on which the injury was discovered [12]. In the case of minors, however, the statute of limitations commonly is added to the age of majority; this allows for filing of suits up until the child reaches the age 18 or 21. In certain cases with extreme brain injury, courts have ruled that the age of majority is never reached and there is no statute of limitations. After a case is filed, the doctor or nurse should not discus the case with colleagues or friends. Any conversation about the case outside of a peer-review situation or with the defendant’s attorney is discoverable. Ultimately, the nurse who provided care most likely will be deposed. The nurse will be asked about what is documented on the record and also about what he or she recalls independently about the case. The nurse will be asked if he or she discussed the case or care with anyone else, including the patient and family. If so, the nurse will be asked what was said. A deposition is taken under oath and must be truthful. The deposition testimony can be read in the courtroom and compared with the courtroom answers to the jury. The trial testimony can deviate little, if any, from the nurse’s earlier deposition testimony. After the facts are gathered, the case may be settled out of court, go to arbitration or mediation, or go to a trial. If a jury finds that practitioners were negligent and the negligence caused injury, percentages of negligence are decided and a monetary settlement is awarded. Hypothetically, if $10 million is awarded
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and the obstetrician is found 90% negligent and is insured for $1 million, the policy will pay the $1 million. If the nurse is found to be only 10% responsible, the hospital may have to pay the remaining $9 million. Perinatal nurses need to be cognizant of common areas of litigation and strategies to reduce their risk for liability when caring for women and newborns. Although legal actions against nurses are escalating, providing safe and high quality care is the best preventive strategy. In the following section, we address some of the most common allegations against perinatal nurses and provide recommendations for safe patient care and protection for the perinatal nurse.
Common allegations in perinatal nursing and risk reduction Since July 2001, Joint Commission on Accreditation of Healthcare Organizations has required that patients be informed if an error or unexpected outcome occurred [13]. Although this may have not led to significantly more medical malpractice lawsuits, there is evidence that the settlements and jury verdicts have increased in amount substantially. The Chicago Lawyer 2004 Settlement Survey found that birth-trauma cases led to 5 of the 10 largest settlements in Illinois in 2003, including the largest settlement of the year—a $35 million agreement. Although these types of cases accounted for only 15% of the reported 97 total settlements, the pay-outs in birth-trauma cases accounted for 25.5% ($144.7 million of $567.57 million) of total settlement funds [14]. Dr. John C. Nelson, a practicing obstetrician/gynecologist who served as president of the American Medical Association, concluded that the system has become more confrontational and adversarial, yet it has not identified the bad doctors or improved the quality of health care [14]. The most common types of lawsuits in which perinatal nurses have been named include the catastrophically brain-injured infant, nonbrain injury obstetric injuries, brachial plexus injury, wrongful fetal or neonatal death, injury to the mother, and wrongful maternal death. There have been several key, repetitive allegations made against nurses that have been associated with the above injuries. Alleged nursing acts of negligence that could result in a malpractice case as well proactive strategies for the nurse to fulfill the nursing standard of care will be addressed.
Failure to assess Goals of Healthy People 2010 include reducing fetal and perinatal deaths from 6.8 and 7.3/1000, respectively, in 1997 to 4.1 and 4.5/1000 in 2010. Another goal is to reduce the maternal death rate from 9.9 per 100,000 to 3.2 per 100,000 [15]. To achieve these goals, regionalized perinatal care is coordinated between basic, specialty, and subspecialty care units and interhospital transfer is encouraged when appropriate [16]. Claims have been made that if a nurse properly assesses a
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patient on admission, a high-risk status may be identified and an indication for transfer to a hospital that can provide a higher level of care may be recognized. The attending physician—not the nursing staff—has the ultimate responsibility for initiating a patient transfer; however, nurses have involvement in the process and share accountability with the physician [16]. On admission or presentation, the professional nurse is responsible for assessing patients in a time frame to meet the general needs of their patient population. Thus, if a prolonged period of time occurs between presentation for care and actual evaluation, the nurse may be deemed liable for complications that could have been prevented if they had been identified and corrected earlier. The nurse needs to take an adequate history, assess the condition of the women and fetus, and recognize findings that require immediate action. The nurse is responsible for notifying the certified nurse midwife or physician in a timely and effective manner. Various events during labor or in the postpartum period may have an influence on maternal vital signs. The perinatal nurse needs to identify significant changes in maternal vital signs and recognize symptoms of maternal complications that may occur (eg, a mother’s blood pressure may be lowered by epidural analgesia, medications, or hemorrhage). The nurse needs to be able to distinguish signs that may coexist that are alarming. To decrease the risk of liability, the perinatal nurse should assess the patient according to recommended protocols. Assessments and communication with the patient’s physician should be documented clearly.
Failure to document adequately Legally, the medical record is the single, contemporaneous valid record of events. The plaintiff’s attorney will use the adage ‘‘if you didn’t document it, you didn’t do it.’’ During a deposition or trial a nurse might have the opportunity to present additional information, although a jury may not consider undocumented evidence as strongly as contemporaneous documentation in the medical record. The record should provide evidence that the nurse’s actions were consistent with the standards of nursing practice. A plaintiff’s attorney may argue that the standard of care was breached by the nurse who did not document care. Because many fetal and maternal complications are not anticipated, comprehensive documentation of assessments and care are imperative. Nurses should focus on objective documentation and avoid speculative nurses’ notes. Nurses should report their assessment findings and avoid assumptions about the source of the injury in charting, even if told so by another practitioner [17]. For example, it is inappropriate to document that a neonate has perinatal asphyxia. Documentation of the patient’s status, assessments, care rendered, physician notification, and response is expected. The nursing process and critical thinking should be evident in the nurses’ notes or other documentation. Many hospitals have exchanged nursing care plans for clinical practice guidelines that may be individualized for the particular patient. Such clinical practice guidelines should be evidence-based [18]. In patient care, the nurse needs to be familiar with,
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and conform to, the contents of the standardized nursing care plans or clinical practice guidelines. Sometimes, patient care becomes such a high priority that documentation must suffer. The nurse should document retrospectively, indicating that the note is a retrospective note or late entry. Additionally, some institutions use documentation by exception or flowsheet charting. These methods may leave the nurse vulnerable because the nurse is required to use more judgment about what is documented. Complete documentation may protect the nurse who may not be able to recall the details or specifics of the case at a later time.
Failure to perform appropriate telephone triage The labor and delivery nurse is not the mother’s physician nor midwife and should not accept calls for triage regarding maternal–fetal status. The physician or midwife should take these calls or the patient should be instructed to come in for evaluation [19]. If, however, a nurse works for an institution that does accept telephone triage or questions, written protocols and mechanisms for physician or midwife follow-up should be in place. Documentation of such a call should be part of the patient’s records.
Failure to interpret fetal monitoring properly Common areas of litigation regarding electronic fetal monitoring tracings include the failure to identify, treat, document and report a nonreassuring fetal heart rate (FHR). Nurses are obligated to have the knowledge and expertise to provide fetal assessment and interpret fetal monitoring tracings accurately, provide appropriate independent nursing interventions, and ensure appropriate assessment and care [19]. Interdisciplinary policies and procedures of an institution should clarify competencies and provide guidelines for assessment and documentation. Methods of intrauterine resuscitation should be incorporated into these documents. Joint in-service education sessions for physicians and nurses on fetal assessment help to assure a standardized knowledge base for the medical and nursing team. According to current guidelines, the method of fetal surveillance in labor may vary, depending on the risk assessment at admission and the preference of the patient and providers. Initial assessment of fetal status is performed on admission. If no risk factors are present at the time of admission, the FHR may be auscultated every 30 minutes in the active phase of the first stage of labor and every 15 minutes in the second stage of labor. If electronic fetal monitoring is used, assessment intervals should be the same. For patients who have risk factors, the FHR should be assessed every 15 minutes in the active phase of the first
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stage of labor and every 5 minutes in the second stage of labor. When electronic fetal monitoring is used, documentation should reflect evaluation of the tracing at the recommended intervals. All providers should use accepted terminology (eg, accelerations, early decelerations, variable decelerations, late decelerations, variability) [16]. Printing and archiving FHR tracings provides valuable information for future reference. The electronic fetal monitor strip needs to be saved as part of the mother’s medical record for as long as a malpractice suit can be filed. Electronic tracings are being filed and accepted with the records into court.
Failure to possess proper knowledge and competency A perinatal nurse is required to be knowledgeable and competent in his or her field of practice. Nurses share the responsibility with their institutions in evaluating their competency and seeking resources to keep current. Competencybased orientations assure institutions that nurses are able to use equipment and provide care for patients in various situations. Lack of current education in the areas of fetal heart rate interpretation [20], in particular, as well as in neonatal resuscitation, are common areas of litigation. Continuing education and certifications help to maintain competency. Standards of care of professional organizations and regulatory agencies should be maintained and available at health care institutions and incorporated into policies. By meeting the standards of care and maintaining competency, the nurse reduces the risk of liability.
Failure to initiate the chain of command The chain of command concept should be familiar to all nurses who provide patient care in any setting. The chain of command is a specific course of action that involves administrative and clinical lines of authority that are established to ensure effective conflict resolution in patient care situations. This mostly is applicable in emergency situations. The concept of the ‘‘captain of the ship’’ no longer relieves the nurse from the responsibility of ensuring adequate physician response. Nurses have a duty to be a patient advocate through the organizational chain of command when they know or believe that the physician is unresponsive to concerns about the patient’s condition, is making inappropriate patient care decisions, or if a true conflict exists [21,22]. The nurse must have actual knowledge of incorrect physician performance. Examples of when to initiate the chain of command are if the physician has alcohol on his/her breath or if there is a clear disagreement about the presence of a nonreassuring electronic fetal monitoring strip. The chain of command would not be initiated when the physician is in the process of delivering a baby and the nurse expects an imminent delivery.
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Improper use of agents for induction of labor Sometimes, it is claimed that the nurse improperly administered misoprostol (Cytotec) or oxytocin (Pitocin) or permitted the physician or nurse midwife to do so. Cytotec is a synthetic prostaglandin E1 analog that originally was used as a gastrointestinal medication; it is used to ripen the cervix and for induction of labor. Uterine hyperstimulation and rupture can result. Case reports of rupture of an unscarred uterus exist [23]. Nurses should follow policies for administration that also delineate fetal and uterine monitoring. Cytotec should not be given more often than every 3 to 6 hours (up to 4 dosages in 24 hours) or to a woman who has a scarred uterus. Oxytocin should not be administered simultaneously. Documentation of times of administration are important. Improper administration of oxytocin may result in uterine hyperstimulation with or without a nonreassuring FHR pattern. Hyperstimulation of the uterus may, or may not, be dose-related [18,24]. There are various regimens for the administration of oxytocin. The nurse needs to assess the electronic fetal monitor strip carefully; if hyperstimulation occurs, the oxytocin should be decreased. If a nonreassuring FHR pattern accompanies the hyperstimulation, appropriate measures should be undertaken.
Improper management of shoulder dystocia Cases of shoulder dystocia injuries sometimes are based upon a failure to diagnose and predict the problem accurately [19], although these are not within the scope of nursing practice. Once a shoulder dystocia is diagnosed, prompt action is necessary to decrease fetal hypoxia. It is essential that the nurse, under the direction of the physician, avoid fundal pressure or cease fundal pressure after the shoulder dystocia has been identified. The McRoberts maneuver, followed by suprapubic pressure may be indicated. Other maneuvers fall under the scope of the physician or midwife. If delivery has been delayed for a significant amount of time, a depressed neonate may result and resuscitation needs can be anticipated.
Failure to begin a Cesarean section in a timely manner Current guidelines direct that institutions are able to begin an emergency Cesarean section within 30 minutes of the decision to perform one. The prudent nurse clarifies the emergent or nonemergent nature of the Cesarean section with the physician and documents the plan and time in the patient record. All personnel who are needed should be mobilized promptly according to the institutional policy. Although the primary responsibility for positioning anesthetized patients resides with the anesthesiologist, the nurse may share this responsibility to ensure that uterine displacement is maintained and that positioning to prevent nerve injury is accomplished. According to the Guidelines for Perinatal Care,
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subspecialty hospitals should have in-house obstetric and anesthesia coverage 24 hours per day. Fetal surveillance should continue until the sterile abdominal preparation is begun unless an internal fetal scalp electrode was used. An internal monitor should be left in place until the abdominal preparation is completed [16].
Failure to obtain informed consent Patients may claim that they were not informed of a procedure or potential complications. In many situations in which medical care or treatment is provided to an individual, medical professionals are required to obtain the patient’s ‘‘informed consent.’’ Although the specific definition of informed consent varies from state to state, informed consent requires that a medical provider tell a patient all of the potential benefits, risks, and alternatives that are involved in any surgical procedure, medical procedure, or other course of treatment, and must obtain the patient’s consent to proceed. It is the role of the physician—rather than a hospital representative, nurse, or other related health care professional—to speak to patients about informed consent. If this duty is breached and injuries result, the patient may have a legal claim for damages. Occasionally, the failure to obtain informed consent is a form of medical negligence and may give rise to a cause of action for battery. In certain situations, informed consent is an absolute necessity. For example, in any medical trials or experiments, informed consent must be obtained from any human participant or subject. Informed consent is not required for situations that involve routine medical procedures (eg, phlebotomy) or if the patient is unconscious and unable to communicate [25]. A mentally disabled person may have an appointed guardian who is authorized to make medical decisions and give informed consent for that individual. Some states allow young adults who are younger than 18 years of age to give their own informed consent for treatments that are related to pregnancy, substance abuse, mental health, and sexual activity. In most situations, parents can give informed consent for treatment of their minor children. The perinatal nurse needs to be aware of the individual requirements regarding informed consent and ensure that a valid consent is on the chart for elective or experimental procedures. If present when the informed consent is obtained, the nurse should document the process and the patient’s understanding. If a nurse witnesses an informed consent, the nurse is only witnessing the signature.
Inadequate staffing or improper delegation A nurse manager may be named as a defendant in a lawsuit, even if he or she had no direct patient care involvement but is involved in staffing and workload decisions. Several studies demonstrated that nursing workload affects the quality of patient care and safety. Increasing the nurse’s workload affects the
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process of care, including the ability of the nurse to monitor patients safely and complete all related nursing tasks [26]. A plaintiff’s attorney may question a nurse in such a manner that the nurse agrees that the unit was extremely busy or that the nurse felt overworked. The next question usually is related to what the nurse did about this, if anything. If a unit is extremely busy, the nurse has the duty to discuss the assignment with the charge nurse and go up the chain of command with his or her concerns, if necessary. Because of reduced staffing, nurses are finding it necessary to delegate some of the responsibilities of patient care to licensed practical nurses, nurse externs, and nurses aids. When entrusting care to other health care providers, nurses have an obligation to delegate according to the state nurse practice act as outlined by the State Board of Nursing [27].The registered nurse who makes the assignment has the accountability for it. To decrease liability when delegating patient care, the nurse manager must consider the stability of the patient, staff competencies, and availability and accessibility of resources [28].
Failure to provide adequate neonatal resuscitation Approximately 1% of all newborns requires resuscitation efforts to survive and to make the transition from intra- to extrauterine life. Another 10% of newborns, although not needing a full resuscitation effort, will require some type of support to make a successful transition to extrauterine life [29]. If the first few minutes of life are not handled competently, these fragile infants may face a lifetime of consequences. Reviews of litigated cases identified that the most serious errors that occur during neonatal resuscitation are failure to anticipate the arrest; failure to have appropriate personnel available; failure to have necessary equipment available; and performance of delayed, inadequate, or improper resuscitation [19,30]. To prevent these errors from occurring, perinatal nurses must complete a thorough history and physical examination on each newly admitted patient with the intent of identifying high-risk conditions that might affect the neonate. Careful monitoring of the maternal condition during labor also will enable perinatal nurses to identify changes in maternal-fetal status. This allows the nurse to anticipate the needs of the neonate and notify the necessary personnel to attend the delivery. At delivery, routine assessment and neonatal care should include resuscitation in accordance with the American Heart Association and the American Academy of Pediatrics Neonatal Resuscitation Program. In addition, one person at each delivery should be responsible to care only for the neonate. Every team of health care providers at a delivery should possess at least one individual who has the skills to initiate and perform a complete resuscitation. Resuscitation must be initiated without delay; all equipment and supplies that are required must be located conveniently for use during the anticipated resuscitation [16]. A complete neonatal resuscitation should be well-documented. A standardized neonatal resuscitation form provides a quick and efficient method for document-
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ing minute by minute changes in condition of the neonate and the corresponding medical response. Methods of decreasing liability include mock neonatal resuscitation practice sessions and regular certification and recertification in neonatal resuscitation.
Failure to treat neonatal hypoglycemia Hypoglycemia is a common problem that is experienced by neonates in the postpartum period. Neonates who experience protracted periods of untreated hypoglycemia can develop serious long-term neurologic complications, such as mental retardation and learning disabilities [31,32]. Failure to monitor for hypoglycemia in the high-risk neonate or failure to recognize the signs of hypoglycemia in any neonate are two common malpractice claims against perinatal nurses. Term, asymptomatic healthy infants do not need routine monitoring of blood glucose levels during the immediate postpartum period; however, neonates who are at risk for hypoglycemia need to be evaluated, even if asymptomatic. Many factors can affect the neonate’s glucose metabolism; it is essential for the perinatal nurse to be aware of maternal and neonatal risk factors. All infants who are at risk must be screened in a timely fashion. Delays in screening may lead to neonatal injury that is related to prolonged hypoglycemia. In addition, all symptomatic infants must be screened and treated promptly. Usually, the perinatal nurse is responsible for monitoring blood glucose levels in the neonate. It is essential that institutional policies for screening be followed and results of screening blood glucose assessments and evaluations of infant condition be communicated in a rapid fashion to the neonatal nurse practitioner or physician. Although controversy continues as to the definition of neonatal hypoglycemia and the determination of an absolute value at which injury occurs, there is no question that prolonged exposure to hypoglycemia can lead to neonatal injury.
Failure to treat for neonatal group B streptococcus sepsis Despite the publication of treatment guidelines by the Centers for Disease Control in 1996 and 2002, group B streptococcus (GBS) remains a common cause of neonatal infection. Early-onset GBS disease typically is identified within the first 24 hours of life. It is particularly difficult to diagnose GBS sepsis during the neonatal period because neonates often display subtle signs or changes in behavior that may have many causes [33]. The best practice for the perinatal nurse is to consider any infant who is not behaving normally as potentially septic. Nurses who care for newborns should obtain a detailed history from the nurse who cared for the mother during the intrapartum period. That history should include GBS status of the mother and any other information that might indicate
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increased risk for sepsis. Double checking the obstetric record with a verbal report provides the nurse with more comprehensive information about the condition of the mother and the newborn. All neonates should be assessed regularly during the first 24 hours of life for any behaviors that might indicate the development of sepsis. Low-risk neonates and neonates who are at risk for the development of sepsis must be monitored. If clinical signs of early-onset sepsis are identified, a full diagnostic evaluation is warranted [34]. Careful documentation of all findings and timely communication of findings to medical care providers are essential to reduce neonatal injury. The perinatal nurse can reduce liability by observing carefully any neonate that displays subtle signs, changes, feeds poorly, or has temperature instability. The nurse needs to be vigilant about documenting and communicating all significantly abnormal findings. Delays in treatment can lead to fulminant disease and possible death.
Summary Obstetric and neonatal nurses are expected to provide an abundance of guidance, support, monitoring, and education to women during and after delivery. Nurses should adhere to standards of practice and provide safety for the mother and fetus or neonate by sometimes ensuring that others are practicing according to the standards of care. Perinatal nurses also are responsible for providing routine assessments and initiating and performing emergency interventions. This includes recognition of the symptoms of complications in the mother and the neonate, resuscitation, and activation of the emergency system. Although the perinatal nurse continues to be at risk for malpractice vulnerability, risk reduction techniques are available to them.
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