Shoulder Dystocia Documentation

Documentation

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 in order to develop the best techniques for dealing with them.

2) An injury following a shoulder dystocia delivery often results in medical-legal actions. Accurate, contemporaneous documentation of what the provider did and what his or her thought process was will be invaluable in defending the care that was given.

Acker (1991) described what careful documentation of a shoulder dystocia delivery should include:

1) Exact times of events.

2) Description of the maneuvers used.

3) Estimation of the traction forces exerted.

The note must be legible and must be written or dictated shortly after the events so that it 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 present.

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.

Yet how one teaches proper documentation and tries to assure that it is done correctly in practice has proven problematic.

Crofts (2008) set up a program in which midwives and junior and senior obstetricians in six hospitals in southwest England were trained in all aspects of shoulder dystocia care. Part of the training included a 40 minute practical workshop on documentation of shoulder dystocia deliveries. At the end of a simulation each participant was asked to document what they had done. In a total of 110 participants, only 56% documented the head-to-body delivery interval with 56% of these overestimating the time by more than one minute. The force used during the simulation was documented by 70.9% of participants. Documentation of force was more likely if a preformatted medical record sheet was provided.

Croft’s conclusion:

1. Maneuvers performed were well documented.

2. Head-to-body delivery intervals and force applied were not documented accurately in the majority of simulated deliveries.

3.Use of a preformatted sheet appears to improve completeness but not accuracy of documentation.

Moragianni (2013) reviewed the charts of 100 vaginal deliveries complicated by shoulder dystocia before and 81 after the implementation of a standardized delivery form. Charts that included the standardized delivery form were more likely to describe important parameters about the delivery. He concluded that inclusion of a standardized form in the delivery record improves the rate of comprehensive documentation of shoulder dystocia deliveries.

Comeau (2014), on the other hand, trained 18 residents in shoulder dystocia documentation after which he tested them. The results: there was no difference in the quality of reporting on shoulder dystocia deliveries compared to that prior to training.

Accurate documentation of events in a shoulder dystocia delivery is important for both medical and medical-legal reasons. This is a skill that has to be taught. There are tools—such as delivery note templates—that can increase the accuracy and compliance with such documentation—but such training efforts have not been uniformly successful.

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