You are the chief compliance officer for the Columbia Hospital for Women. The hospital's chief nursing

officer, Shelby Taylor, has just walked into your office to get your advice regarding hospital policy.

Jane Rudd, pregnant with her second child, has just been admitted to the obstetrics ward at full term and in labor. Her records reveal that her first delivery of a healthy 7.5 pound baby was uncomplicated. Upon admission this morning, Ms. Rudd stated that she does not want continuous electronic fetal monitoring (CEFM). CEFM involves the placement of two sensors attached to the patient's abdomen with elastic belts: one to monitor the strength of contractions, and another to monitor the fetal heart rate. The sensors are tethered to a machine at the patient's bedside. Tracings from the sensors can be monitored by nurses at the central nursing station on the obstetrics ward. The sensors can be disconnected periodically for brief periods of time to allow the patient to visit the bathroom, but otherwise, CEFM requires the laboring patient to remain in or near the hospital bed throughout labor and delivery and to shift position as little as possible to maintain accurate readings.

Ms. Rudd wishes to be free to shift position, move freely, and walk around the obstetrics ward with her partner during labor as part of her plan to manage pain without the use of drugs. She would like the nurses to intermittently monitor her contractions and the fetal heart rate as needed, rather than being connected to the monitors continuously.

Brianna Gardner, the nurse assigned to care for Ms. Rudd, correctly told the patient that hospital policy requires CEFM for all patients in labor. Ms. Rudd responded that she did not need CEFM during her first labor (at another hospital), which went well, and she expects the same experience again. Nurse Gardner then spoke with Ms. Rudd's obstetrician, Dr. Cohen, who said that she is willing to allow the patient to forgo CEFM if the hospital is willing to do so. If the hospital agrees, Dr. Cohen will sign standing orders for the nurses on duty to intermittently monitor Ms. Rudd's contractions and the fetal heart rate using a method referred to as "hands-on listening" with a fetal Doppler device. The nurses would be ordered to monitor Ms. Rudd in this fashion every 15-30 minutes during the active phase of the first stage of labor and every 5-15 minutes during the pushing phase of the second stage of labor. During the first stage of labor, the nurses would be instructed to contact Dr. Cohen immediately if the measurements fall outside of specific parameters. Nurse Gardner sought guidance from Nurse Taylor regarding how she shouldrespond to the patient's request.

The nurses and doctors involved in the case are split over the issue. Nurse Taylor (the chief nursing officer) argues that the policy is a wise measure intended to protect infants, and Nurse Gardner agrees. Nurse Taylor points to guidelines issued by the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN), which recommend "initial and ongoing" assessment of EFM tracings. Nurse Taylor interprets this language to mean that hospital staff should actually watch EFM tracings continuously throughout labor and delivery or have the monitors set to trigger alarms if the readings exceed safe parameters. In addition, she notes, CEFM shields staff from accusations that the best care was not provided, if a bad outcome occurs.

The patient's obstetrician, Dr. Cohen, contacted the hospital's chief medical officer, Dr. Cortez. Dr. Cortez explained to you that the hospital's policy may be out of date in light of recent studies showing

that intermittent monitoring with hands-on listening is as safe as CEFM for the fetus and is actually safer than CEFM for the laboring patient, because CEFM is associated with a greatly increased risk of unnecessary surgical Caesarean section, which poses greater risks of infection and other complications for the patient during and after delivery. Dr. Cortez points to a statement from the American College of Obstetricians and Gynecologists (ACOG) endorsing hands-on listening as an "appropriate and safealternative" to CEFM for laboring patients without complications. In addition, a recent ACOG committee report states that "Continuous EFM has not improved outcomes for patients with low-risk pregnancies" and recommends that care providers should "consider training staff to monitor using a handheld Doppler device . . . which can facilitate freedom of movement and which some patients find more comfortable." ACOG states that hands-on listening may not be appropriate for patients at increased risk of complications such as those with meconium staining, bleeding during labor, suspected fetal growth restriction, preeclampsia, prior Cesarean, type 1 diabetes, or those receiving Pitocin. Dr. Cortez acknowledges, however, that most doctors and nurses feel more comfortable with CEFM because it is what they have been trained and because they feel it protects them from malpractice liability.

The hospital has two working handheld fetal Doppler devices, which are more costly to purchase and maintain than the EFM monitors it provides in every labor and delivery room. One of the nurses currently on duty has had extensive training in hands-on monitoring, whereas all of the nurses on staff are trained and certified for CEFM.

What steps would you advise the nurses and doctors involved in this case to take today to provide appropriate care for Ms. Rudd?

What legal and compliance considerations would you advise the chief medical officer to take into account as he decides whether to revise the hospital's policy going forward? Who else should he consult?

If Dr. Garcia does decide to revise the policy, what additional steps should be taken, from a compliance perspective?