Date of Award

January 2013

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Christian M. Pettker

Subject Area(s)

Medicine

Abstract

Shoulder dystocia (SD) is difficult to predict and one of the most highly litigated obstetrical emergencies. Consequently, our institution implemented a standardized SD form in order to help facilitate adequate and accurate documentation in cases of SD. Our study aimed to utilize the information recorded in the newly implemented SD form to investigate the demographics of patients, practices, and outcomes in SD cases at Yale-New Haven Hospital (YNHH) and to study the effect of implementing a standardized SD form on medical record documentation practices.

We collected 41 discrete data points from the SD form and the medical record in cases of SD occurring at our institution. We identified SD cases beginning in January 2004 and tracked inclusion of delivery information in the SD form and in narrative delivery notes for one year before and four years after implementation. Overall, 152 consecutive cases of SD were included and the presence as well as

the mean and standard deviation, or percentage, for each data point was collected and calculated.

Elements from the SD form increased significantly in narrative delivery notes after implementation of the form (p=.011). Data elements included at higher rates in the medical record after implementation included estimated prepregnancy maternal weight (13% to 28%, p=.043), total maternal pregnancy weight gain (19% to 36%, p=.033), estimated fetal weight (60% to 77%, p=.025), time of onset of active labor (40% to 65%, p=.004), time of onset of second stage (27% to 52%, p=.003), and time of head delivery (4% to 30%, p=<.001). The demographics of our patient population

were comparable to that of others reported in the literature.

Our results show that use of a mandatory SD form results in significant improvements in documentation within provider narrative delivery notes and may improve the attention of providers to more complete and accurate charting. Such improvements in documentation may better demonstrate standards of care in the management of SD cases and decrease litigation exposure when events are reviewed.

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