Midwives Litigation Malaysia

Litigation Issue on
Midwives Profession and
Carrier Pathway in Malaysia
ZAINI BINTI DAHIRAN
UNIVERSITY MALAYA MEDICAL
CENTRE
KUALA LUMPUR, MALAYSIA.
23 JANUARY 2016

Learning Outcome
1. State the code of conduct for
midwives in Malaysia.
2. Define the litigation.
3. Explain the liability in clinical
practice.
4. Explain the importance to prevent
complications to mother and baby.

Vision
 Nursing in Malaysia will be delivered
by capable, effective, competent,
skillful and highly knowledgeable
nurses who will be able to provide
safe and holistic nursing care.

Focus
Provision of effective, holistic care to
individuals, families and community
across the life span.

In Malaysia
Laws governing practice of Nursing and
Health Care Practice:
 Nurses Act 1950
 Midwives Act 1966
 Dangerous Drug Act 1952
 Medical Act 1971
 Prevention and Control of Infectious Disease Act
1988
 Birth and Death Registration Act 1957
 Human Tissue Act 1974
 Occupational Safety and Health Act 1994 (OSHA)
 Private Healthcare and Facility Act 1998

Midwives Act 1966
 The Midwives Act 1966 establishes a
Midwifes Boards provides for the
registration of nurse-midwifes and
regulates the practice of midwifery in
the country.

MIDWIVES BOARD MALAYSIA
THE CODE OF PROFESSIONAL
CONDUCT AND PRACTICE OF A
MIDWIFE
Code of Conduct
1. The midwife shall maintain at all times the
highest standard of care and professional
conduct. She shall not leave a woman in labour
unattended, she shall pass over her duties to the
midwife covering for her, and must hand over the
management of mothers at risk to relief midwife
before leaving her operational area.

MIDWIFE CONT….
2. The midwife must not only be well
prepared to practice her art but must also
maintain and improve knowledge and skill
at a consistently high level

3. The midwife must recognize and respect the
uniqueness and dignity of each individual and respond
to their needs appropriately, irrespective of their ethnic
origin and religious
beliefs, social standing and the nature of their health
problems.
4. The midwife shall hold in confidence all personal
information entrusted to her and make disclosures only
with consent or when required by the order of a court.
MIDWIFE CONT….

5. The midwife acknowledges the responsibilities and
recognizes the limitations of the professional functions.
She should not prescribe or perform any procedure
outside her scope of responsibilities without medical
orders except in emergencies and to report to the
medical practitioner at the earliest opportunities.
MIDWIFE CONT….

6. The midwife works in a collaborative and co-operative
manner with health care professionals and others
involved in providing care. Any incompetence or
unethical conduct of her associates should be exposed
but only to the proper authority
7. The midwife should not abuse her privileged
relationship with mothers and the privileged access
allowed to her
MIDWIFE CONT….

8. The midwife is entitled to an appropriate
remuneration.
9. The midwife should not permit her name to be used
in connection with the advertisement of commercial
products or with any other forms of self-advertisement
10. The midwife’s behavior and conduct should conform
and adhere to standards of personal and professional
ethics which should not discredit upon the profession.
MIDWIFE CONT….

Litigation
Litigation arising from clinical negligence,
whist representing only the tip of the
iceberg of claims, complaints, incidents
and mistakes which do not result in harm,
nevertheless provides a valuable
retrospective analysis on the anatomy of
error.

What is litigation?
The process of taking a case to a court
of law so that a judgment can be made
(Cambridge English
Dictionary)

What is litigation?
 Litigation is the term used to describe
proceedings initiated between two
opposing parties to enforce or defend a
legal right.
 Litigation is typically settled by
agreement between the parties, but may
also be heard and decided by a jury or
judge in court.

Nurses’ Liability
 Liability means legal responsibility : a
nurse is legally responsible for actions
that fail to meet the standard of care
or for failing to act and thereby
causing harm.

Common causes of Liability
Nursing actions fells into following
categories
1. Treatment
2. Communication
3. Medication
4. Monitoring, observing, and
supervising.

Nursing Negligence Cases
Treatment
1. Enema to a preoperative patient with
appendicitis, which resulted in ruptured bowel
and appendicitis.
2. Improperly used equipment, resulting in air
embolism.
3. Failure to administer the correct oxygen level
4. Failure to attach a fetal monitor as ordered.
5. Burns to an infant from formula heated in a
microwave.
6. Failure to attend a patient having an asthma
attack, resulting in injuries such as brain

Communication
1. Failure to notify the physician of
changes in signs and symptoms
2. Failure to chart vital signs for hours in
a labor room.
3. Failure to advise the physician of
jaundice.
4. Failure to notify the physician of
circulatory compromise in a casted
leg

Medication
1. Wrong medication given on discharge
(topical eye anesthetic instead of
artificial tears)
2. Failure to give diazepam as ordered.
3. Improper administration of potassium
chloride.

Monitoring/ Observing/ Supervising
1. Failure to recognize dehydration and
electrolyte imbalance.
2. Failure to monitor intravenous therapy
3. Failure to monitor fetal heart rate.
4. Negligent supervision of a psychiatric
patient who attempted suicide
5. Negligent assignment and supervision
of a student nurse who did not take
blood pressure for 6 hours.

Liability in Obstetric Nursing
1. Failure to detect signs and symptoms
of fetal distress
2. Failure to perform proper nursing
functions when fetal distress is
detected (e.g. turning patient on side,
administering oxygen, calling the
physician)
3. Failure to notify the physician in a
timely manner of problems or
deterioration of the patient’s condition.

In patient obstetric care results in more
50% of obstetric and gynecology claims
(White, Pichert, Bledsoe, Irwin, & Entman,
2005)
Literature Review

Fetal monitoring, neurologically impaired
children, neonatal death, shoulder
dystocia, uterine rupture, and ‘decision-to-
incision’ time were identified as clinical
factors frequently present in obstetric
malpractice cases.
( American College of Obstetrician and Gynecologist ,
2003).
Literature Review cont…

In a review of over 800 obstetric practice
from the medical malpractice company
owned by the Harvard medical
community,
the average payment in obstetric-related
malpractice claims was more than twice
that of other clinical areas, with birth
asphyxia, shoulder dystocia, intrauterine
fetal death, and maternal hemorrhage
accounting for the majority cases
(Crico Strategies,
2010)

Angelini and Greenwald’s (2005) review
of 65 closed claims involving nurse –
midwives found assessment of fetal
monitoring and shoulder dystocia to be
the major sources of liability risk.
However, no knowledge of the
frequency, location, or experience of
midwives involved in litigation was
available.

Contributing factors to the adverse
events were noted to be inappropriate
management of pregnancy, failure to
timely diagnose and treat “fetal distress”
and inappropriate management of the
second stage of labor via operative
vaginal birth
(Crico Strategies, 2010)

Symon (200) conducted a survey of 1790
midwives and 211 physicians that aimed to
examine birth practitioners’ and perceptions
of the incidence of both malpractice litigation
and defensive clinical practice. The survey
found that a large majority of both midwives
and obstetricians believed that the frequency
of lawsuits has been increasing in recent
years, and that clinical practice was
becoming defensive.

Midwives cited more detailed
documentation, earlier consultation, and
increased adherence to institutional as
examples of personal practice changes
resulting from fear of litigation.
Literature Review cont…Literature Review cont…

Being a defendant in a malpractice
lawsuit is known to be difficult and
stressful experience
(ACOG ,2005)

Practitioners’ emotional responses to
litigation are multifarious and include
denial, anxiety, guilt, shame, and
isolation.
ACOG (2005) and Symon
(2005)

COMMON AREAS OF LIABILITY AND
PATIENT HARM IN CLINICAL
PRACTICE

Common areas of liability and patient
harm in clinical practice
1. Fetal heart rate pattern interpretation,
communication, and documentation
Common allegations
 Failure to accurately assess maternal-fetal
status
 Failure to determine that the tracing being
recorded is of maternal rather than fetal origin
 Failure to appreciate a deteriorating fetal
condition
 Failure to accurately communicate the
maternal-

2. Oxytocin for labor
induction/augmentation
Common allegation
 Initiation of oxytocin in the absence of
evidence of fetal well-being
 Failure to accurately assess maternal-
fetal status during labor induction
 Excessive doses of oxytocin resulting
in uterine tachysystole, with or without
an indeterminate or abnormal FHR
harm in clinical practice cont…

3. Fundal pressure during the second stage of
labor
Common allegations
 Application of fundal pressure during second
stage of labor that resulted in shoulder
dystocia and/ or other maternal-fetal injuries
 Application of fundal pressure during shoulder
dystocia that further affected the shoulder and
delayed the birth, resulting in maternal-fetal
injuries.

4. Shoulder dystocia
Common allegations
 Failure to accurately predict risk of
shoulder dystocia
 Failure to diagnose labor
abnormalities
 Application of fundal pressure during
shoulder dystocia, further affecting the
shoulder and delaying birth, thereby
resulting in maternal-fetal injuries

5. Second-stage labor management
Common allegations
 Failure to appreciate deteriorating fetal status
 Failure to act on deteriorating fetal status by
modifying maternal pushing efforts and
initiating and usual intrauterine resuscitation
measures
 Injuries to the perineum that resulted in
perineal lacerations, loss of pelvic floor
integrity, and sexual dysfunction.

6. Neonatal resuscitation at birth
Common allegations
 Failure to anticipate resuscitation needs
of a baby whose mother experienced
pregnancy complications and/or after an
indeterminate or abnormal FHR pattern
during labor
 Failure to have appropriate personnel
and equipment available for neonatal
resuscitation.

Preventing Lawsuits
1. Effective communication
 SBAR (situation, background,
assessment, recommendation) which
provides a framework for
communicating information that requires
a clinician’s immediate attention and
action in a specific, structured format.

2. Medical record
 Charting in medical record, whether it
is still paper or, an electronic health
record is the best way to display the
care provided.
Preventing Lawsuits cont…

3. Rapport with clients
 Establishing a rapport with the client
through honest, open communication
goes a long in avoid lawsuits.

4. Current Nursing Skills
 Keeping one’s nursing knowledge and
skills current is vital to preventing errors
that may lead to lawsuits.
 Taking advantage of in-service training,
workshops, and continuing nursing
education classes is an important part
of maintaining the nurse’s skill level.

5. Knowledge of the client
 Recognizing the client who is lawsuit
prone can help reduce the risk for
litigation.
 Common characteristics of this type of
client include constant dissatisfaction
with the care given, constant complaints
about all aspects of care, and negative
comments about other nurses.

Conclusion
 Nurses are governed by laws and
regulation to ensure safe practice
 Nurses should have knowledge about
law and its implication in nursing
practice.

Midwives Litigation Malaysia

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