Documentation Requirements for Shoulder Dystocia
The correct answer is (b) Maternal serum pH results - this should be EXCLUDED from the shoulder dystocia procedure note as it is not a standard or relevant component of shoulder dystocia documentation.
Essential Components of Shoulder Dystocia Documentation
When documenting a shoulder dystocia event, comprehensive and accurate record-keeping is critical for patient care continuity and medicolegal protection. 1 The following elements should be systematically included:
Required Documentation Elements
Team members present must be documented, as this information is essential for establishing who participated in the emergency management and demonstrates appropriate resource mobilization. 1
Fetal head position (specifically which shoulder was anterior) should be recorded, though studies show this is frequently omitted - only 18-78% of providers correctly document this critical detail. 2, 3 Accurate identification of the anterior shoulder is essential for understanding the mechanism of dystocia and the appropriateness of maneuvers performed.
Elapsed time of shoulder dystocia (head-to-body delivery interval) is a crucial element that should be documented. 1, 2 However, studies reveal that providers frequently overestimate this interval by more than 1 minute in 56% of cases, and only 45-56% of residents document this timing at all. 2, 3
Additional Critical Documentation Elements
Beyond the options listed in the question, comprehensive shoulder dystocia documentation should include:
Sequence and timing of maneuvers performed - The McRoberts maneuver should be documented as first-line intervention, followed by any secondary maneuvers. 4, 5 Studies show 91% of providers correctly document the order of maneuvers used. 2
Maternal factors: prepregnancy weight, total weight gain, and estimated fetal weight 1
Labor characteristics: duration of active labor and second stage 1
Neonatal outcomes: Apgar scores, birth weight, and immediate assessment for brachial plexus injury or clavicle fracture 5, 2
What Should Be EXCLUDED
Maternal serum pH results are not relevant to shoulder dystocia documentation. While fetal pH assessment (through scalp stimulation or scalp pH) may be relevant during labor for fetal monitoring, 6 maternal serum pH has no role in shoulder dystocia management or documentation. This laboratory value does not contribute to understanding the mechanism, management, or outcomes of the shoulder dystocia event.
Common Documentation Pitfalls
Incomplete documentation is widespread: 76% of residents recorded fewer than 10 of 15 key components in their delivery notes after shoulder dystocia. 2 The use of standardized preformatted documentation forms significantly improves completeness, with increased inclusion of critical elements like estimated fetal weight (60% vs 77%), duration of second stage (27% vs 52%), and head-to-body delivery time (4% vs 30%). 1
Inaccurate force documentation: 70.9% of providers document force used, but there is no relationship between subjective descriptions and actual measured force applied. 3 Providers should avoid excessive traction on the fetal head and fundal pressure. 5
Underrecognition of shoulder dystocia: Approximately 71% of neonates with injuries consistent with shoulder dystocia (brachial plexus injury or clavicle fracture) were delivered without obstetric recognition of the dystocia, representing a critical documentation and recognition failure. 7