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System Errors in Intrapartum Electronic Fetal Monitoring:A Case ReviewLisa A. Miller, CNM, JD

Intrapartum electronic fetal monitoring (EFM) interpretation and management continue to be a commonissue in litigation involving adverse outcomes in term pregnancies. This article uses a case study approachto illustrate system errors related to intrapartum EFM. Common system errors related to use of intrapartumEFM include knowledge deficits, communication failures, and fear of conflict. Strategies for reducing errorand the promotion of a patient safety approach to risk management in EFM are discussed, with an emphasison the importance of a true team approach to EFM education, interpretation, and management. J MidwiferyWomens Health 2005;50:507–516 © 2005 by the American College of Nurse-Midwives.
keywords: labor, fetal monitoring, risk management, education, communication barriers
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NTRODUCTION

lectronic fetal monitoring (EFM) is currently the mostidely used technology in intrapartum care in the Unitedtates, despite questions of efficacy.1 Although argumentsor the abandonment of continuous EFM in low-risk preg-ancies continue to be proffered and deserve a thoughtfuleview, this article addresses the risk management issuesssociated with intrapartum use of EFM.2 Allegationsegarding the interpretation and management of EFMracings dominate obstetric litigation related to neurologi-ally impaired infants. In addition, obstetric litigationontinues to account for a disproportionate share of medicalalpractice indemnity payments.3 Simpson and Knox have

dentified several common plaintiff’s theories, or allega-ions, related to EFM, including 1) failures in the assess-ent and treatment of nonreassuring fetal heart rate (FHR)

atterns, 2) communication failures, 3) lack of appropriateesponse by clinicians, and 4) failure to use chain ofommand to resolve clinical disagreements.4 Allegations ofedical, midwifery, or nursing error made by a plaintiff inspecific case may or may not be accurate. But there is nooubt that medical errors occur, and their occurrence is aignificant problem.5

Research in the arena of medical error tells us that whenhe allegations are valid (i.e., when errors occur), they areore likely the result of a complex multiplicity of factors,

ersus the performance failures of single individuals.6 Thispproach of examining error is called a systems approach,nd it allows recognition of both active failures, which areailures of clinicians directly involved in patient care, andatent failures, which are failures in areas such as adminis-ration, design, or implementation.7 For example, the fail-re of a clinician to recognize an abnormal FHR patternay be due to lack of knowledge (active failure) but may be

ompounded by fatigue due to lengthy call schedules (latentailure), a lack of training in the clinician’s original educa-

address correspondence to Lisa A. Miller, CNM, JD, 2014 West Cullom,hicago, IL 60618. E-mail: [email protected]

ournal of Midwifery & Women’s Health • www.jmwh.org2005 by the American College of Nurse-Midwives

ssued by Elsevier Inc.

ion program (latent failure), or lack of skills assessment byhe employer or credentialing body (latent failure). Thus,rror prevention is not simply the removal or retraining ofhe individual clinician involved, but rather, a restructuringnd reworking of the system that created the conditionsnder which error became not just a possibility (there willlways be errors in any human endeavor) but a probability,“more likely than not” scenario.Training and education in EFM vary widely for certifiedidwives (CMs), certified nurse-midwives (CNMs), phy-

icians, and nurses.7–9 This fact, coupled with the continuedredominance of EFM issues in obstetric negligencelaims, make FHR interpretation, management, and com-unication critical areas of concern for clinical practice asell as risk management. The following case study and

nalysis serve as an example of common errors in EFM andow a systems approach can provide solutions for futurerror prevention. The case facts and outcome are presentedrst, followed by a discussion of the fetal monitoring

ssues, system errors, and risk management strategies ap-licable to clinical practice.

ASE PRESENTATION

24-year-old primigravida was admitted at term in latentabor during the early morning hours by the CNM on call.he patient had an unremarkable antenatal course and noignificant risk factors. Figures 1 to 14 reflect pertinentortions of the FHR tracing; the shaded area in each figurendicates the range of normal baseline rate from 110 to 160eats per minute (bpm).The initial FHR tracing was normal, with a baseline rate

f 120 bpm, moderate variability, the presence of FHRccelerations, and the absence of FHR decelerations (Fig-re 1). The CNM ordered oxytocin augmentation at 10:00M, secondary to suspected arrest of dilation and inadequateterine contractions. The patient’s dilation was noted to becm at this time; however, effacement and station were not

ecorded. Oxytocin was begun by the labor and deliveryurse (RN) at 10:30 AM. At 11:45 AM, the CNM performed
n artificial rupture of membranes (AROM) and noted clear
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mniotic fluid; the patient was 5 cm, with vertex (vtx) at �1tation (Figure 2). At 12:00 PM, the patient requested pain

isa A. Miller, CNM, JD, teaches multidisciplinary fetal monitoring programsationally and is president of Perinatal Risk Management and Educationervices. She is in clinical practice as a certified nurse-midwife at Saintnthony Hospital in Chicago, Illinois.

Figure 1. Patient’s admission tracing.

igure 2. Artificial rupture of membranes (AROM) for clear fluid at 11:45 AM

and not repetitive.

08

edication and a paracervical block (PCB) was adminis-ered by the CNM at 12:05 PM (Figure 3).

Within minutes of instituting the paracervical block, theHR became bradycardic, and the external Doppler wasoted to be doubling the FHR on the tracing printoutFigure 4). A fetal scalp electrode (FSE) was placed, theatient was repositioned several times, and oxygen was

represent RN noting fetal movements.

. Note the minor FHR deceleration, unremarkable when associated with AROM
(arrow)
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dministered via a face mask. Oxytocin infusion wasiscontinued approximately 10 minutes after the bradycar-ia started (Figure 5). The RN noted at this time that theNM was on the phone with the physician, but there waso note by either the RN or CNM regarding the details ofhe conversation about the EFM tracing (Figure 6). Al-hough the patient remained on her left side with oxygen onnd the pitocin off, the CNM left the room to attend anotherirth. The RN became concerned about the FHR tracing

Figure 3. Normal tracing following AROM, patient requests pain relief

Figure 4. Within minutes of PCB, FHR bradycardia occurs, with electronic fet

ournal of Midwifery & Women’s Health • www.jmwh.org

Figure 7) and brought the tracing to the CNM, whoeassured her that the FHR pattern was “just some vari-bles.” At this point, the second call to the physician waslaced by the RN, who questioned the CNM’s interpreta-ion of the FHR tracing. The physician told the RN that ifhe CNM was not concerned, he was not concerned, andeclined the RN’s request to come to the hospital andersonally evaluate the tracing.The RN continued to observe the tracing (Figures 8 and

prepared for and given a paracervical block (PCB) at 12:05 PM (arrow).

al monitor exhibiting doubling of the FHR via Doppler (closed arrows).

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) and notified the CNM and physician of the loss ofariability and rising baseline at 1:05 PM (Figures 10 and1). The physician again declined to come in to assess theatient. At 1:10 PM, FHR baseline was 170 bpm with absentariability and questionable late decelerations. The RNalled the physician for the third time and informed him ofhe FHR tracing, at which point he stated he was on his wayo the hospital. Arriving at 1:20 PM, the physician immedi-tely decided to perform an emergency cesarean deliveryFigure 12). The patient was taken to the operating room

Figure 5. Placement of an ISE reveals FHR bradycar

Figure 6. Undulating FHR resembling a sinusoidal pattern10 (arrow

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OR) and monitoring was continued in the OR up to theoint of abdominal incision (Figures 13 and 14). The infantas delivered with APGAR scores of 3/3/8 at 1, 5, and 10inutes, respectively. No cord gases were obtained at birth.he infant was transferred and cared for in the neonatal

ntensive care unit of a Level III perinatal center nearby,here he remained until his discharge at 5 months of age.e experienced both early-onset multisystem organ in-olvement and early-onset severe neonatal encephalopathyonsistent with an acute intrapartum hypoxic event. Litiga-

ow represents discontinuation of pitocin at 12:20 PM.

). CNM is on the phone with the physician during this time.


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ion ensued and no settlement offer was proffered by theospital, CNM, or physician defense teams. At the time ofrial, the child was 5 years of age and severely compro-ised on all levels. One week prior to trial, the child died

rom complications following a seizure. A settlement washen reached by the parties, the terms of which werendisclosed.

igure 7. Atypical FHR pattern that most closely resembles sinusoidal but lthe RN and CNM.

Figure 8. Another atypical FHR pattern (black arrows), similar to the lamb


ISCUSSION

lthough this case involved the use of a paracervical block,arely used today for labor analgesia, the case is actually abouthe clinical response to the FHR changes occurring after thearacervical block. The plaintiff’s allegations primarily fo-used on 1) the CNM’s and the RN’s failure to identify an

e required uniformity. Mistakenly identified as variable decelerations by both
acks th
da pattern11 but lacking normal baseline variability (white arrows).

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bnormal or nonreassuring FHR tracing; 2) failure to correctlyanage the ongoing abnormal tracing; 3) the RN’s failure to

se chain of command appropriately; and 4) the physician’sailure to come in to the hospital and evaluate the tracingarlier. There was no argument that once the physician arrived,he team appropriately proceeded to cesarean delivery.

A review of the case based on the plaintiff’s allegationsf error is helpful. Initially, the FHR tracing meets recog-ized standards for normal (i.e., it was a reassuring FHR

Figure 9. Rising FHR baseline with decreasing variabi

Figure 10. FHR baseline becomes tach

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attern10–12 in that it had a normal baseline rate, moderateariability, and FHR accelerations). Following the paracer-ical block, the FHR pattern became bradycardic, a knownotential side effect following paracervical block,13 whichften spontaneously resolves within a few minutes andoses no problem for the fetus. In this case, however,he FHR pattern remained bradycardic for greater than0 minutes (Figures 4–6), a situation clearly indicative ofsignificant risk for fetal hypoxia. Although the Pitocin

ssic secondary changes indicative of fetal hypoxia.10,11

ycardic and loses all variability.


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as stopped, and intrauterine resuscitative measures werenstituted, neither the RN nor the CNM recognized theeverity of risk associated with a bradycardia of 60 to 70pm, validating the plaintiff’s first allegation.The basic error that occurred first was related to lack of

nowledge. A review of the depositions of both the RN andhe CNM revealed that although the RN had several coursesn EFM, she was unfamiliar with the use of paracervical

igure 11. Probable development of subtle late decelerations of FHR (arrotocotransducer.

Figure 12. Tachycardia and absent variability persist. Physician arrives (arro


locks and their effect on FHR, whereas the CNM hadimited EFM education (lectures in midwifery school, nother training) and her experience in interpreting variantatterns was minimal.The combined RN/CNM lack of expertise led to the

econd error, the failure to correctly manage the ongoingbnormal tracing. The unusual patterns the fetus exhibitedn Figures 7 and 8 were misinterpreted by the CNM as

lthough interpretation is hindered by lack of uterine activity recording via
ws), a
w) and immediately orders preparations for primary cesarean delivery.

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ariables, and although the RN appeared to understand thathe FHR pattern was not normal, she acquiesced to theNM interpretation when told to do so by the physician.hus, the plaintiff’s second allegation is validated, anngoing error on the part of both the RN and CNM toorrectly manage an atypical nonreassuring FHR pattern.

The multiple phone calls placed to the physician by theN demonstrate her awareness that the FHR pattern wasbnormal, but her failure to either insist on the physician’s

Figure 13. Patient is transferred to the operat

Figure 14. FHR tracing is continued in OR up to point of incision. Infant is del

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resence or use chain of command to engage the assistancef a supervisor or other hospital staff gives credence to thehird plaintiff’s allegation. Although the failure on theNM’s part to recognize the ongoing abnormalities of theHR tracing reflects her lack of knowledge, the RN’scquiescence and failure to use chain of command effec-ively stems from a fear of conflict, an error related toeamwork dysfunction.7,14

The physician’s misplaced trust in the CNM’s ability to

(OR) where FHR tracing is continued (arrow).

ivered with APGAR scores of 3/3/8 at 1, 5, and 10 minutes, respectively.


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ccurately interpret the EFM tracing, coupled with his lackf trust of the nurse’s assessment that the CNM wasncorrectly interpreting the pattern, resulted in his laterrival on the scene, and the validation of the fourthllegation of error, resulting in a delay in delivery of wellver 1 hour following the onset of the bradycardia. Thehysician’s deposition revealed that he made no assessmentf the CNM’s EFM interpretation skills upon hiring her,nd he assumed she had the requisite knowledge to interpretntrapartum FHR patterns. He agreed that the tracing wasbnormal following the paracervical block, but he main-ained that neither the RN nor CNM had informed him ofhe significant abnormalities until the tachycardia and lossf variability were reported to him (Figure 10). This isnother type of teamwork dysfunction, which can beescribed as avoidance of accountability or responsibilityhifting.14,15

Although it is impossible to determine whether thishild’s outcome would have been different had a cesar-an delivery been performed immediately, even the mostenerous review of the case facts reveal a failure on theart of the RN and CNM to appropriately recognize andespond to a nonreassuring tracing, and the poor com-unication between team members resulting in a serious

elay in intervention. None of the clinicians made theserrors intentionally. How could the system be designedor in this case, redesigned) to prevent similar errors inhe future?

ISK MANAGEMENT STRATEGIES

he Nature of Accidents

lthough it is beyond the scope of this article to addressrganizational accident theory in detail, a brief overviews helpful to the risk management discussion that fol-ows. Organizational accidents have been defined byeason as rare but catastrophic events that occur inigh-risk, high-technology systems.15 Perinatal unitsave been identified as one such system, and the appli-ation of principles of organizational behavior to peri-atal units, while in its infancy, is not new.16 Perinatalnits, like other high-risk, high-technology organiza-ions, operate with many built-in defense mechanismshat work to prevent errors from occurring. Maintainingppropriate staffing levels, the credentialing of healthare providers, proper training of staff, and individualccountability for competency are only a few examplesf these defenses against error, which form what can beonceptualized as multiple layers of protection againstccident or error.

In a perfect world, all the defenses against error wouldunction without flaw. But in reality, every layer ofefense has the potential for flaws or vulnerability. Theseholes” in the layers of defenses may create “windows ofpportunity” for serious accidents to occur.15 This
ramework for understanding accidents is called the m

Swiss Cheese model,” and it has been used in under-tanding causation of adverse perinatal outcomes byimpson and Knox.17

Application of this type of accident framework to thease at hand reveals a number of identifiable weaknesseshat, in conjunction with one another, created a situationhat resulted in an adverse outcome.

nadequate Knowledge

n the preceding case, there were three key areas thatreated the probability of error. Inadequate knowledgen the part of the RN and CNM was the first crucial area.ultiple authors have recommended the establishment

f multidisciplinary EFM education programs in anffort to ensure an adequate knowledge base for alllinicians.3,4,7,9,16 In addition, the adoption of a stan-ardized nomenclature for EFM is recommended.4,7,9 In997, a standardized nomenclature was published after anterdisciplinary group of experts was convened by theational Institute of Child Health and Human Develop-ent.12 Current EFM textbooks use the standardized

omenclature,10,11 and a sample hospital policy fordoption of the nomenclature has been published.7 Fi-ally, a plan for ongoing EFM competency should bevery clinician’s responsibility, whether it is throughormal continuing education programs, self-study mod-les, or hospital-based programs.3,4

eam Dysfunction: Fear of Conflict and Poor Communication

nfortunately, even the most well-educated clinicianill be set up to fail if operating in a system where

ommunication is problematic. The recent Sentinelvent Alert issued by the Joint Commission on Accred-

tation of Healthcare Organizations (JCAHO) found thatommunication issues were identified as root causes in2% of the reviewed cases of perinatal death or perma-ent disability, with more than half of the institutionsdentifying organizational culture as a barrier to success-ul communication and team cooperation.18 Nurses,Ms, CNMs, and physicians have a responsibility tonsure the safety of the patient at all times. The conceptf chain of command, or chain of communication,nables clinicians to reach out beyond the immediatelinical circle when circumstances warrant. But if anyeam member is anxious about communicating due toear of conflict, a serious defense against error may beompromised. In the case above, the RN was concernedhat the CNM was not correctly interpreting the FHRracing and attempted to get the physician to come in toersonally evaluate the tracing. Her failure to institutehain of communication illustrates a classic fear ofonflict scenario. As Greenwald and Mondor note,Some nurses are often so reluctant to ‘cause trouble’nd so fearful of the consequences that such trouble
ight represent that they refuse to use chain of
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ommand.”2(p. 104) Teamwork training, similar to theype of training used in the airline industry and noweing applied to medicine, is one method that may helpeduce the fear of conflict by making all the players (e.g.,linicians) equally important when a matter of patientafety is at issue.18,19

Fear of conflict is only one aspect of team dysfunction.he lack of response by the physician in this case, evenhen contacted multiple times by the RN, was another

xample of team dysfunction. Perhaps the RN could haveeen more assertive, or perhaps the lack of a standardizedomenclature hampered adequate communication betweenhe RN and physician about the FHR tracing abnormalities.learly, it would have been better to have had the physi-ian’s evaluation earlier rather than later. Physician pres-nce to evaluate a patient at the request of a nurse is aharacteristic of perinatal units at low risk for adverseutcomes.16 CMs/CNMs should welcome and encouragehysician involvement when issues of competing EFMnterpretations arise between themselves and nursing staff.

ONCLUSION

ack of knowledge, fear of conflict, and poor communicationre three areas that contribute to error in obstetrics andspecially in EFM interpretation and management. There areany other error-producing conditions, such as fatigue and

xcessive workload, which need to be addressed in the interestf patient safety. As advocates for women and families, CMsnd CNMs must be willing to look at errors systematically,ithout blame, and with an eye toward reducing error andaking patient safety a primary concern. In the area of EFM,

his includes not only proper patient selection, but ensuringhat all clinicians using EFM share an adequate knowledgease and an environment that encourages open communica-ion and a true team approach to care.

EFERENCES

1. Parer JT. Electronic fetal heart rate monitoring: A story ofurvival. Obstet Gynecol Surv 2003;58:561–3.

2. Curtin SC, Park MM. Trends in the attendant, place, and timingf births, and in the use of obstetric interventions: United States,989–97. Centers for Disease Control and Prevention. Natl Vital Statep 1999;47:1–13.

3. Greenwald LM, Mondor M. Malpractice and the perinatal

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4. Simpson KR, Knox GE. Common areas of litigation related toare during labor and birth: recommendations to promote patientafety and decrease risk exposure. J Perinat Neonat Nurs 2003;17:10–25.

5. Institute of Medicine. In Kohn LT, Corrigan JM, DonaldsonS. To err is human. Washington (DC): National Academy Press,

000.

6. Shojania KG, Wald H, Gross R. Understanding medical errornd improving patient safety in the inpatient setting. Med Clin Northm 2002;86:847–67.

7. Miller LA. Safety promotion and error reduction in perinatalare: Lessons from industry. J Perinat Neonat Nurs 2003;17:128–38.

8. Murphy AA, Halamek LP, Lyell DJ, Druzin ML. Training andompetency in electronic fetal monitoring: A national survey. Obstetynecol 2003;101:1243–8.

9. Simpson KR, Knox GE. Risk management and electronic fetalonitoring: Decreasing risk of adverse outcomes and liability expo-

ure. J Perinat Neonat Nurs 2000;14:40–52.

10. Menihan CA, Zottoli EK. Electronic fetal monitoring: conceptsnd applications. Philadelphia (PA): Lippincott, Williams & Wilkins,001.

11. Freeman RK, Garite TJ, Nageotte MP. Fetal heart rate moni-oring, 3rd ed. Philadelphia (PA): Lippincott, Williams & Wilkins,003.

12. National Institute of Child Health and Human Developmentesearch Planning Workshop. Electronic fetal heart rate monitoring:esearch guidelines for interpretation. Am J Obstet Gynecol 1997;77:1385–90.

13. Parer JT. Handbook of fetal heart rate monitoring, 2nd ed.hiladelphia (PA): W. B. Saunders, 1997.

14. Lencioni P. The five dysfunctions of a team. San FranciscoCA): Jossey-Bass, 2002.

15. Reason J. Managing the risks of organizational accidents.urlington (VT): Ashgate, 1997.

16. Knox GE, Simpson KR, Townsend KE. High reliability peri-atal units: Further observations and a suggested plan for action.Healthcare Risk Manage 2003;23:17–21.

17. Knox GE, Simpson KR. Adverse perinatal outcomes. Recog-izing, understanding, & preventing common accidents. AWHONNifelines 2003;7:224–35.

18. JCAHO. Preventing infant death and injury during delivery.entinel Event Alert 2003;30:1–3.

19. Helmreich RL, Schaefer HG. Team performance in the oper-ting room. In Bogner MS. Human error in medicine. Hillsdale (NJ):

urse. J Perinat Neonat Nurs 2003;17:101–9. Lawrence Erlbaum Associates, 1994:225–53.


system errors in intrapartum electronic fetal monitoring: a case review

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