Standardization sometimes elicits strong negative feelings: "no one is going to tell me how to practice"; "a threat to autonomy"; "cookbook medicine"; "devalues critical thinking"; "I'm not a robot," etc. However, standardization of key clinical practices known to be associated with risk of harm to mothers and babies is a fundamental principle of perinatal high reliability and patient safety (Knox, Simpson, & Townsend, 2003). "There is no high reliable organization that develops guidelines for use in critical situations that are even remotely affected by concerns for preservation of pilot or operator autonomy" (Clark, Belfort, Byrum, Meyers, & Perlin, 2008, p.1e2), yet in many perinatal units standardization has been challenged on this basis and substantial resistance to practice changes is ongoing. We all need to work together to overcome this resistance to promote a safer care environment. Fortunately, recent evidence has provided more data to support standardization in obstetrics.
Some clinical leaders and their healthcare systems were early adopters of clinical standardization and have been sharing their positive outcomes in the literature. Encouraging results based on standardization of care processes during labor and birth, such as fetal assessment, labor induction/augmentation, administration of oxytocin, misoprostol, and magnesium sulfate, operative vaginal birth, and handling of shoulder dystocia, were recently published (Clark et al., 2008; Clark et al., 2007; Mazza et al., 2007; Mazza et al., 2008). Because these care processes are the source of many of the reported cases of preventable adverse maternal and fetal outcomes, their standardization based on current evidence and published professional standards and guidelines is warranted to promote patient safety (Knox et al., 2003). Selected significant positive reported results include a decrease in length of labor, overall oxytocin dose, cesarean birth rate, various maternal and fetal adverse outcomes, birth trauma rate, operative vaginal birth rate, late preterm births, admissions to the neonatal intensive care unit, adverse perinatal events, number of obstetrical professional liability claims, costs of claims, and an increase in clinicians' perception of the perinatal patient safety climate. You should review this literature together with members of the perinatal team to support standardization of key clinical practices during labor and birth.
Patient safety is created through professional accountability based on standardization, simplification, and clarity, as supported by the principles of high reliability safety science. Although standardization of unit practices, protocols, and policies may be perceived as a threat to autonomy or an inconvenience to some team members, administrative leaders and clinicians should be supportive and acknowledge that the collective good of mothers and babies is the primary goal.
Opportunities for Clinical Standardization During Labor and Birth
* Use standard definitions for fetal heart rate patterns in all professional communication
* Use standard intrauterine resuscitation measures when the fetal heart rate pattern suggests fetal compromise
* Develop criteria for elective labor induction that includes >= 39 completed weeks of gestation and cervical readiness
* Develop a standard oxytocin policy linked to standard physician orders consistent with physiologic and pharmacologic principles
* Consider use of checklists before initiation of oxytocin and increases in oxytocin rates that include a normal fetal heart rate pattern, absence of uterine tachysystole, and evaluation of labor progress
* Develop a standard process for handling shoulder dystocia and conduct periodic shoulder dystocia drills to ensure that all clinicians are in sync with what is expected during this emergency
* Develop standard practice related to operative vaginal birth consistent with current evidence and vacuum manufacturer recommendations
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