Improved overall delivery documentation following implementation of a standardized shoulder dystocia delivery form

Abstract

OBJECTIVE: Our objective was to evaluate whether using a standardized shoulder dystocia delivery form improved documentation. A standardized delivery form was added to our institution's obstetrical record in August 2003. METHODS: A retrospective cohort study was conducted comparing 100 vaginal deliveries complicated by shoulder dystocia before, and 81 after implementation of the standardized delivery form. The two groups were compared in terms of obstetric characteristics, neonatal outcomes and documentation components. RESULTS: Charts that included the standardized delivery form were more likely to contain documentation of estimated fetal weight (82.7% vs. 39.0% without the form, P<0.001) and head-to-shoulder delivery interval (76.5% vs. 15.0% without the form, P<0.001). Both groups were statistically similar in terms of documenting estimated blood loss and fetal weight, umbilical cord pH, type and order of maneuvers utilized to relieve the shoulder dystocia, and second stage duration. CONCLUSIONS: Inclusion of a standardized form in the delivery record improves the rate of documentation of both shoulder dystocia-specific and general delivery components.