Liability and Risk Management Issues in Midwifery


Midwives face liability issues daily, and everyday they search for strategies to improve patient safety and limit risk. The recent malpractice insurance crisis, coupled with new patient safety directives, has refocused our attention on risk modification and error reduction. This issue of the Journal of Midwifery & Women's Health (JMWH) provides a continuing education opportunity to identify both salient risks in clinical midwifery practice and mechanisms to limit liability.

The concept of closed claims analysis has been used, especially by anesthesiologists, to review risky practice patterns and heighten awareness of selected liability concerns.1 Closed claims analysis is a methodology that can suggest corrective action for future clinical practice. The article in this issue by Diane J. Angelini and Linda Greenwald reviews 65 closed midwifery malpractice claims. In this review, fetal heart rate interpretation and management ranked first, and shoulder dystocia ranked second in liability claims.

This issue of JMWH contains 2 articles that approach fetal heart rate interpretation from very different perspectives. The article by Jennifer Fahey examines the physiology underlying perinatal asphyxia. This clinical review strengthens the understanding of fetal oxygenation as it is reflected in the fetal heart rate. Lisa Miller uses a case study approach to identify system errors. Evaluation of systems allows a shift in focus from retrospective blaming of an individual to prospective assessment and plan for error prevention. This technique addresses not only clinical errors but also the structure and process of providing care. As a model for system change, this can be a valuable tool. Both of these articles identify ways to reduce error: 1) by improving understanding to decrease the likelihood of error and 2) by strengthening the system to increase the likelihood that errors will be caught.

Shoulder dystocia, followed by permanent brachial plexus injury or mental impairment, remains a leading cause of malpractice allegations in obstetrics. In an extensive review by Cecelia Jevitt, strategies are offered to maximize positive outcomes when shoulder dystocia ensues.

Annie Clark has contributed a review of the current literature on vacuum-assisted delivery and discusses issues relevant to incorporating this procedure into midwifery practice. These include placement of the device, detachments, complications, and indications for use in the context of midwifery philosophy and liability.

Because laws and governance affect midwifery practice, the impact of the Emergency Medical Treatment and Active Labor Act (EMTALA) affects midwifery practice in obstetric triage.2 An update on EMTALA and commonly identified risks in obstetric triage practice are presented in the article by Diane Angelini and Laura Mahlmeister. Correct interpretation of EMTALA regulations is crucial to limit liability and reduce fines.

Shifting from intrapartum issues to a less frequently considered but equally important area, Jan Kreibs' article on risks in ambulatory practice reminds the reader once again of the importance of communication and documentation.

In keeping with quality improvement and risk reduction, the first full description of the American College of Nurse-Midwives' Benchmarking project to improve midwifery practice is included in this issue in an article by Cathy Collins-Fulea et al. Benchmarking measures one's processes and outcomes against “best in class” and is part of any quality improvement program in clinical practice.

An issue comprised of articles emphasizing the pitfalls and legal risks of practice must be daunting to the reader. However, the best defense in clinical practice is to identify, understand, and remediate the inevitable risks and abnormalities that are encountered daily in clinical practice.