Patient Safety Strategies for Surrogate Births

Surrogate pregnancies present unique challenges that require planning and clear communication. Consider the following case example and patient safety strategies to help you anticipate and avoid unexpected situations.

Case Example

A patient at 35 weeks’ gestation with twins presented to the local hospital’s maternity emergency department and requested to be examined. She was concerned because she was having contractions that were increasing in frequency and duration. Her obstetrician was out of town. Another obstetrician, who was unfamiliar with the patient, was covering call for the weekend.

After examining the patient, the on-call obstetrician learned that the patient was a surrogate. The obstetrician also learned that a birth plan had not been established and that the patient and intended parents had differing views about expectations for the birth process. The on-call obstetrician was able to contact the patient’s primary obstetrician, who provided additional patient information but was unable to come to the hospital to manage the patient’s care.

The patient was offered a trial of labor as her condition warranted, but the intended parents were adamantly opposed to it. The dynamics of the situation declined as discussions focused on visitors to the patient’s hospital room. Although the patient was permitted to have visitors, she did not want family members of the intended parents in the room.

The patient elected to have a vaginal birth and delivered Baby A without incident. Immediately after the birth of Baby A, Baby B exhibited fetal distress with a sustained drop in heart rate that was unresponsive to maternal interventions, including repositioning, oxygen, and intravenous fluid boluses. A decision was made to deliver Baby B by stat C-section.

Baby B was delivered successfully by C-section and required supplemental oxygen for several hours. When both babies were stable, they were discharged from the hospital to the care of the intended parents.

This challenging experience provided the on-call obstetrician with valuable insights on issues surrounding surrogate births. Communication between a patient and her care provider is a key factor in meeting treatment goals and ensuring that the patient has a positive experience. In the case of a surrogate pregnancy, good communication among care providers, patient, and intended parents is essential. If critical information—including a contingency plan—is not established prior to a birth event, the delivery care team may be faced with a difficult situation.

In addition, it is important to understand a state’s relevant informed consent laws. Unless the law has determined otherwise, the patient can make care decisions for herself and the unborn child. The intended parents generally have no decision-making rights until the child is born.

Patient Safety Strategies

• Communicate clearly with surrogate patients and discuss possible scenarios that may occur if unexpected situations arise. Provide specific scenarios in advance. As illustrated by the case example, possible scenarios include disagreements over a trial of labor, intended parents’ family visitors, and attendees present for the birth. Having advance discussions may alleviate stress during the pregnancy and eliminate potential conflicts between the patient and intended parents.
• Encourage the surrogate and the intended parents to seek separate and independent mental health counseling and independent legal representation (required in some states) to fully explore the psychological, ethical, and legal issues surrounding surrogacy.
• Review the written agreement between the surrogate and the intended parents for guidance on situations documented in the contract.
• Document the prenatal chart regarding expectations of the surrogate and intended parents—including discussions concerning informed consent for the risks and complications of pregnancy, procedures, and medications. (For further guidance on informed consent, see our articles “Informed Consent: Substance and Signature” and “Informed Refusal.”)
• Familiarize yourself with state laws and the policies and protocols at your hospital or birthing center regarding surrogate births.
• Structure effective handoffs when transitioning the care of your patients to on-call providers, and include well-documented birthing plans.
• Understand applicable HIPAA restrictions and facility policies regarding photography and visitation, and communicate them to the patient and intended parents.
• Discuss anticipated patient issues with maternity staff to prepare them for unique patient situations.

For additional assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.