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Delivery notes after shoulder dystocia often lack critical elements

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References

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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