Guidelines: Shoulder Dystocia Documentation

In the case of shoulder dystocia, it is recommended that your delivery note include the following:

  • When and how you diagnosed the dystocia. Also, the position and rotation of the neonate's head.
  • The physicians, nurses and other personnel attending the delivery. In particular, the fact that you called for a pediatrician (or neonatologist) and other assistance as soon as you suspected or knew that you were dealing with dystocia.
  • The maneuvers and procedures you employed, the order in which you employed them, the result or lack of result obtained from each, and the reasons you chose to employ each. (This is your all-important action plan.)
  • The maneuvers and procedures you did not employ, and the reasons you chose not to employ them.
  • The time elapsed from diagnosis to delivery, with the actual or estimated (specify which) amount of time between your initiation of a given maneuver and initiation of the subsequent maneuver.
  • Any pertinent findings or impressions you had during the course of the delivery, and the actions you took as a result.
  • Your impressions of the neonate upon delivery, including the presence or absences of meconium staining, a nuchal cord, evidence that the infant may have sustained an intrapartal injury, and other conditions or events that might affect the neonate's course. Apgar scores.
  • Your impressions of the placenta, and the fact that you ordered pathology inspections of it and the umbilical cord, as well as a cord blood-gas analysis.
  • Any requests you made to the pediatrician or neonatologist to check the infant's shoulder, clavicle, humerus, etc.
  • The mother's condition immediately following delivery, the components and findings of your postpartum exam, and any orders you gave for the mother's care.
  • The fact that you informed the mother of the occurrence of dystocia, your response, and the potential sequelae.
  • The mother's questions, comments and requests regarding the dystocia.
  • Episiotomy timing or tears