When You Need Another Set Of Eyes...
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- •September 23, 2026
Supportive Escalation & Chain-of-Command Guidance for Labor & Delivery Nurses
A practical, AWHONN-aligned guide for communicating concerns and bringing the right resources to the bedside.
ESCALATION IS NOT INSUBORDINATION
Speaking up for patient safety can sometimes feel uncomfortable – especially when it means questioning a plan of care or involving someone higher in the chain of command. Do not allow concern about someone’s feelings, authority, or professional ego to prevent you from escalating an unresolved patient-safety concern. Escalation is a normal part of safe team-based care. Asking a charge nurse, another provider, nursing supervisor, or other appropriate resource to join the conversation is not insubordination. It is a way to support the patient, the team, and your own professional practice. You have a burden of responsibility to escalate a patient safety concern until said concern is resolved.
Why this matters in L&D
Maternal and fetal conditions can change quickly. AWHONN professional resources emphasize nursing assessment, advocacy, effective communication, collaboration, and timely action when patient needs or safety concerns arise. AWHONN also recognizes SBAR (Situation, Background, Assessment, Recommendation) as a structured technique used to frame communication between health care providers about a patient's condition and clinical status.
Consider bringing in additional support when...
- You have a change in maternal or fetal status that needs timely evaluation.
- You have communicated a concern, but the response does not fully address what you are seeing at the bedside.
- The responsible provider is unavailable, delayed, or cannot be reached.
- An order or plan is unclear, seems inconsistent with the current clinical picture, or you need clarification before proceeding.
- The situation would benefit from another perspective, additional expertise, or additional resources.
- You are unsure what to do next. You do not need to wait until you are certain an emergency exists to ask for help.
Know the local pathway before you need it
AWHONN fetal-monitoring guidance highlights familiarity with organizational communication policies, including chain of command, consultation/on-call processes, transfer policies, and conflict resolution. Because every facility is different, identify these resources at orientation or the beginning of your shift.
TRAVELER TIP
Ask early: Who is my charge nurse? Who provides alternate OB coverage? Who is the nursing supervisor? What is the process if a provider cannot be reached? How do I activate emergency or rapid-response resources?
Communicate Clearly, Then Invite Support
Structured communication helps the receiving clinician quickly understand what is happening and what you need. Keep the tone collaborative, the information objective, and the request specific.
| S | Situation | What is happening now? "I'm calling because the fetal heart rate pattern has changed and I'm concerned about the current tracing." |
| B | Background | What context matters? "She is 39 weeks, on oxytocin, and the tracing was previously reassuring." |
| A | Assessment | What are you seeing? "She now has recurrent decelerations despite the interventions completed so far." |
| R | Recommendation | What do you need next? "I'd like you to evaluate her at the bedside now and help determine the next step." |
If the concern is still unresolved
It is appropriate to restate what you are worried about and ask for another resource. The goal is not to prove someone wrong; the goal is to make sure the clinical concern has been heard, evaluated, and addressed.
Clarify: “I want to make sure I communicated this clearly. My concern is ___ because ___.”
Ask: “Would you come to the bedside so we can reassess together?”
Re-state: “I’m still concerned because the patient’s condition has not improved despite ___.”
Invite support: “I’d like to bring in my charge nurse/another provider so we can make sure we have the right support for the patient.”
Escalate: “I’m going to follow the facility’s chain-of-command process so we can get additional clinical support.”
A HELPFUL MINDSET
You do not need to diagnose another clinician's knowledge or competence. Focus on the patient: What are you observing? What risk remains? What response is needed? What additional expertise or resource could help?
A supportive escalation pathway
Bedside RN → Responsible Provider + Charge RN → Alternate OB / Hospitalist / Laborist → Nursing Supervisor → Nursing / Medical Leadership
Use the facility’s actual policy and activate emergency resources immediately when the clinical situation requires them.
What This Can Look Like at the Bedside
Concerning fetal status
You have completed appropriate nursing interventions and notified the provider, but the tracing remains concerning. Give an SBAR update, request bedside evaluation, and involve the charge nurse. If the concern remains unresolved, follow the facility pathway for alternate physician or supervisory support. If the situation becomes emergent, activate the appropriate emergency response.
Maternal condition is worsening
A patient develops a significant change in blood pressure, bleeding, pain, respiratory status, mental status, or another concerning finding. Reassess as appropriate, initiate actions within your scope and facility protocol, communicate the exact findings and trend, and ask for the needed evaluation or treatment. If there is delay while the patient continues to worsen, bring in the charge nurse and escalate promptly.
You believe more expertise is needed
Rather than labeling the attending as “underqualified,” describe the clinical need. For example: “I’m concerned this situation may benefit from additional OB/MFM/anesthesia/neonatal support. Can we involve them?” If the concern remains unresolved, involve charge/supervisory leadership and follow the facility’s consultation and chain-of-command process.
Document the clinical story
AWHONN fetal-monitoring guidance recommends contemporaneous, accurate, objective, and efficient documentation, including relevant assessments, interventions and responses, communication with other clinicians, and communication within the chain of command.
- Document the relevant maternal/fetal assessment and changes over time.
- Document nursing interventions and the patient's response.
- Record when the provider was notified and the clinically relevant information communicated.
- Document requests made, orders received, and objective provider responses.
- Record when charge, supervision, alternate providers, or other resources became involved.
- Continue documenting reassessment and the evolving plan of care.
KEEP IT OBJECTIVE
Instead of: “The doctor ignored me.”
Consider: “Provider notified at 0214 of recurrent decelerations and interventions completed. Bedside evaluation requested. Charge RN notified at 0218 due to persistent concern; additional provider support requested per facility chain of command.”
A final reminder
Strong nurses ask for help. Strong teams make it easy to speak up. When you are concerned, use clear communication, invite another set of eyes, and keep moving through the facility's support structure until the patient's needs are appropriately addressed.
QUICK REFERENCE
When I’m Concerned: L&D Escalation at a Glance
| STEP | WHAT TO DO | WORDS YOU CAN USE | NEXT MOVE |
| 1. Assess | Identify the change, urgency, trend, interventions, and response. | “Here is what I’m seeing now…” | Initiate appropriate nursing actions within scope/policy. |
| 2. SBAR | Give a focused update and a clear recommendation. | “I’m concerned about ___. I recommend/request ___.” | Ask for bedside evaluation, clarification, or a specific action. |
| 3. Reassess | Did the response address the clinical concern? | “I’m still concerned because ___.” | If yes, continue care. If no, bring in support. |
| 4. Get help | Invite charge RN and another appropriate clinical resource. | “Can you come assess with me? I’d like another set of eyes.” | Use alternate OB/hospitalist/laborist or other facility resource. |
| 5. Escalate | Follow the facility’s chain of command when the concern remains unresolved. | “I’m going to follow our chain-of-command process for additional support.” | Nursing supervisor → nursing/medical leadership per policy. |
| 6. Emergency | Do not wait for routine hierarchy if the patient is deteriorating or an emergency is occurring. | “I need emergency support now.” | Activate the facility’s OB emergency / rapid response / code process. |
| 7. Document | Chart the clinical timeline objectively and continue reassessment. | Assessment → intervention → communication → response → escalation. | Document chain-of-command communication and patient response. |
PAUSE POINT
If you are thinking, “I’m not sure this is serious enough to escalate,” that is often a good time to call your charge nurse and ask them to assess with you. You do not have to carry the concern alone.
References & use notes
- Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). AWHONN SBARs: Inclusive and Equitable Patient Care. https://awhonn.org/awhonn-sbars/
- AWHONN. Standards for Professional Nursing Practice in the Care of Women, Newborns, and People Across the Lifespan (2023), listed in AWHONN Women’s Health / Professional & Risk Management Resources.
- AWHONN. Fetal Heart Rate Auscultation, 4th ed. (2024): communication/chain-of-command documentation and objective, contemporaneous documentation guidance.
- AWHONN. Respectful Maternity Care Framework and Evidence-Based Guideline / resources: dignity, autonomy, effective communication, and partnership in care.