Careful documentation of instances of shoulder dystocia and
their resolution is extremely
important for two reasons:
1) Obstetricians want to
learn as much as possible from instances of shoulder dystocia
order to develop the best techniques for dealing with them.
2) Shoulder dystocia is so often the initiating cause of
Acker (1991) described what
careful documentation of a shoulder dystocia delivery should
1) Exact times of events.
2) Description of the
3) Estimation of the traction
The note must be legible and
must be written or dictated shortly after the events so that
is a contemporaneous medical progress note. Acker also
recommends that the note have a
specific form. This would include comments on:
1) Delivery time both for
head and body (the nurse should record this).
2) Episiotomy description and timing.
3) Whether or not anesthesia was present when the shoulder dystocia was recognized and any
additional anesthesia given.
4) Nasopharyngeal suction.
5) Initial traction before shoulder dystocia
is recognized, documenting force and duration.
6) Maneuvers used, listing
them in the order employed.
7) The force used described
in comparative terms such as average, maximal, etc.
8) Duration of maneuvers --
have the nurses know to record this.
9) Personnel -- identify all
10) Estimated fetal weight
and the actual birth weight.
Experience has shown that the
best defense in a medical liability action, whether involving
shoulder dystocia or any other situation, is thoughtful,
articulate, timely documentation of
each decision made in the course of treatment.
Copyright © 2006 Henry Lerner