Documentation Requirements After Shoulder Dystocia
The elapsed time from delivery of the fetal head until complete delivery of the baby (option d) should be documented in the medical record after a shoulder dystocia, as this represents a critical and objective measure of the event.
Essential Documentation Elements
The American College of Obstetricians and Gynecologists specifically recommends documenting the sequence and timing of all maneuvers performed during shoulder dystocia management 1, 2. This timing component is crucial for several reasons:
- Head-to-body delivery interval is an objective, measurable criterion that defines shoulder dystocia severity, with intervals exceeding 60 seconds considered prolonged and associated with significantly worse neonatal outcomes 3
- Studies demonstrate that even relatively brief delays (median of 5 minutes) in delivery of the shoulders may be associated with fatal outcomes, making this documentation medically and legally critical 4
- Implementation of standardized documentation forms that include time from head to body delivery significantly improves the quality of medical records, with documentation rates increasing from 4% to 30% after form implementation 5
Why Other Options Are Not Recommended
Option a (mild/moderate/severe designation): There is no standardized classification system for grading shoulder dystocia severity in this manner. The objective measure is the head-to-body delivery time and maneuvers required, not subjective severity grading 3.
Option b (maternal supplemental oxygen): Maternal oxygen administration after delivery of the fetal head is not a standard component of shoulder dystocia documentation and is not specifically recommended for shoulder dystocia management 1.
Option c (maternal blood pressure): Maternal blood pressure is part of routine labor management but is not a relevant documentation element specific to shoulder dystocia management 1.
Complete Documentation Framework
Beyond the head-to-body delivery interval, comprehensive shoulder dystocia documentation should include:
- The specific sequence of maneuvers performed (McRoberts, suprapubic pressure, rotational maneuvers, posterior arm delivery) in the order they were attempted 1, 2
- Studies show 91% of providers correctly document the order of maneuvers when using standardized forms 2
- Detailed documentation is essential after any delivery complicated by shoulder dystocia for both patient care and medicolegal protection 6
Common Pitfalls to Avoid
- Failing to document the actual time interval allows for unreliable reporting—studies show that obstetric attendants identified only 16 of 27 cases requiring maneuvers as shoulder dystocia when timing was not objectively recorded 3
- The incidence of shoulder dystocia is higher than previously reported when objective criteria (timing and maneuvers) are used rather than subjective recognition alone 3