OB Guideline 5: Resolution of Clinical Discord

Each institution shall have a formal process to resolve differences of opinion or judgment between professional staff about medical management, conduct of labor, or interpretation of tests of fetal status. The process should consider these points:

1. Priority should be given to optimizing quality patient care.
2. In cases of discord, the involved parties shall first discuss the discord and attempt to resolve it. The “two challenge rule,”¹ and other methods of conflict resolution may be considered to facilitate structured communication and avert medical errors.
3. If the involved parties cannot resolve the discord, they should seek assistance, initiating the chain of command² through medical, resident/fellow supervisory physician, midwifery, nursing hierarchy, and/or department leadership, as indicated.^3-4 A list of medical staff, supervisory physician, midwifery, and nursing hierarchy should be available in the clinical areas.
4. All discussions pertaining to differences in clinical opinion should occur among professional staff only, and out of earshot of the patient and family.
5. Differences in clinical observations and opinions should be documented in an objective, non-editorial fashion in the medical record.
6. Unexpected medical incidents should be reported to the institutional risk manager.
7. The occurrence of the discord should be reported to the Chief of Obstetrics, the Director of Nurse Midwifery, and/or the Obstetrical Nursing Director, as indicated.

1. Assertively voicing your concern(s) at least twice to ensure your concerns have been heard by your colleague.
2. A series of steps ascending the administrative and clinical lines of authority established to ensure effective conflict resolution in patient care situations.
3. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-1427. Reaffirmed 2019. doi:10.1097/AOG.0b013e3181c6f90e
4. American College of Nurse-Midwives. Code of ethics with explanatory statements. American College of Nurse-Midwives; Published 2005. Updated 2015. Accessed December 10, 2025. https://midwife.org/wpcontent/uploads/2024/09/Code-of-Ethics.pdf