Shoulder dystocia is a leading cause of litigation in obstetrics, and the delivery note is an indispensable tool in the defense of a case. When investigators from the University of Southern California analyzed 66 delivery notes to determine how many of 20 intrapartum elements were covered, they found that an average of 11 (58%) were documented. No note included all 20 element.
The study was presented as a poster at the 2014 American College of Obstetricians and Gynecologists annual clinical meeting in Chicago.1
The 20 elements and their frequency of documentation were:
- date – 96%
- time – 96%
- maneuvers used to achieve delivery – 91%
- order of maneuvers – 89%
- maternal gravidity and parity – 86%
- mode of delivery – 86%
- Apgar scores – 80%
- type of perineal laceration – 80%
- infant birth weight – 77%
- resident provider – 75%
- head-to-body interval – 58%
- cord gases – 53%
- attending provider – 46%
- whether episiotomy was performed – 39%
- application of gentle downward traction – 31%
- movement of the infant’s extremities after delivery – 30%
- which shoulder was anterior – 21%
- whether the patient was informed of the shoulder dystocia – 4%
- adequacy of maternal pelvis – 2%
- lack of fundal pressure – 1%.
Investigators recommended that providers implement use of a standard form to improve recording of critical elements.
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