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) Shoulder dystocia is so often the initiating cause of medical-legal actions.

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.

Conclusions >>

Copyright © 2006 Henry Lerner