ABOG Risk Management & Mitigation 2 — Questions and Answers
Question 1: A patient undergoing cesarean delivery develops uncontrolled hemorrhage from a placenta accreta spectrum. Which stepwise surgical intervention is most appropriate BEFORE proceeding to hysterectomy?
- Immediate aortic cross-clamping
- Uterine compression sutures and bilateral uterine artery ligation (Correct answer)
- Administration of carboprost only
- Insertion of a Bakri balloon and discharge
Correct answer: Uterine compression sutures and bilateral uterine artery ligation
Uterine compression sutures (e.g., B-Lynch) combined with uterine artery ligation represent recommended conservative surgical steps before hysterectomy in refractory postpartum hemorrhage.
Question 2: Which documentation practice best reduces medicolegal risk when a patient declines recommended fetal monitoring during labor?
- No documentation is needed if the patient verbally declines
- Document the refusal, risks discussed, and patient's understanding in the medical record (Correct answer)
- Only note 'patient refused' in the nursing flow sheet
- Contact hospital legal team before proceeding with care
Correct answer: Document the refusal, risks discussed, and patient's understanding in the medical record
Thorough documentation of informed refusal—including risks explained and patient's demonstrated understanding—creates a defensible medical record.
Question 3: A patient at 34 weeks gestation with suspected sepsis has a lactate of 4.2 mmol/L. What is the most critical immediate intervention per Surviving Sepsis guidelines?
- Oral antibiotics and outpatient follow-up
- IV fluid resuscitation with 30 mL/kg crystalloid and broad-spectrum IV antibiotics within 1 hour (Correct answer)
- Expectant management until cultures result
- Immediate cesarean delivery regardless of fetal status
Correct answer: IV fluid resuscitation with 30 mL/kg crystalloid and broad-spectrum IV antibiotics within 1 hour
Sepsis-3 bundle requires prompt IV fluid resuscitation and broad-spectrum antibiotics within 1 hour when lactate ≥2 mmol/L, signaling tissue hypoperfusion.
Question 4: Which action most effectively reduces wrong-site or wrong-patient surgical errors in obstetric and gynecologic procedures?
- Relying on verbal confirmation from the surgeon alone
- Completing a formal surgical time-out with all team members present before incision (Correct answer)
- Checking the patient armband only at admission
- Documenting the procedure in the chart after the case
Correct answer: Completing a formal surgical time-out with all team members present before incision
The Universal Protocol requires a pre-incision time-out involving all team members to verify patient identity, procedure, and site, reducing never events.
Question 5: A postoperative hysterectomy patient develops fever, tachycardia, and purulent wound discharge on day 4. Which risk management step is most important after initiating treatment?
- Reassure the patient and defer any documentation
- Notify the hospital risk management team and complete an incident report (Correct answer)
- Discharge the patient and follow up by phone only
- Perform a second operation immediately without informing the patient
Correct answer: Notify the hospital risk management team and complete an incident report
Adverse events require timely incident reporting to risk management to facilitate investigation, quality improvement, and appropriate patient communication.
Question 6: When is it most appropriate to invoke an emergency cesarean delivery protocol (Category I fetal heart rate tracing) in a risk management framework?
- When the nurse feels uncomfortable but the FHR is reassuring
- When the FHR tracing shows persistent bradycardia or prolonged decelerations unresponsive to resuscitative measures (Correct answer)
- Only after written consent is obtained from the patient
- When gestational age is less than 32 weeks regardless of tracing
Correct answer: When the FHR tracing shows persistent bradycardia or prolonged decelerations unresponsive to resuscitative measures
Category I emergency cesarean is indicated for nonreassuring FHR patterns unresponsive to intrauterine resuscitation, where delay risks fetal compromise.
Question 7: Which strategy most reduces the risk of retained surgical items (RSIs) during gynecologic laparotomy?
- Rely on surgeon memory for sponge tracking
- Implement standardized surgical counts (opening, closing, and final) with adjunct technology such as radiofrequency detection (Correct answer)
- Perform a routine postoperative X-ray for all cases
- Limit use of sponges to reduce counting burden
Correct answer: Implement standardized surgical counts (opening, closing, and final) with adjunct technology such as radiofrequency detection
Standardized counting protocols combined with radiofrequency or bar-code adjunct technology are evidence-based strategies to prevent retained surgical items.
ABOG Risk Management & Mitigation 2
A patient undergoing cesarean delivery develops uncontrolled hemorrhage from a placenta accreta spectrum.
Which stepwise surgical intervention is most appropriate BEFORE proceeding to hysterectomy?