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Evaluation of Residents’ Delivery Notes After a Simulated Shoulder Dystocia

To the Editor:

We read with interest the recent article by Deering et al, "Evaluation of Residents’ Delivery Notes After a Simulated Shoulder Dystocia."¹ Although the authors have made an initial attempt to study shoulder dystocia documentation, this study appears flawed on many fronts and draws several faulty conclusions.

1. Why did only 16 of 24 (67%) residents from institution 1 and 17 of 24 (70.8%) from institution 2 participate in the study? Moreover, it appears that only a few residents (approximately one third to one half) from PGY2 and PGY3 participated; these are the residents who are doing most of the deliveries at the respective institutions.

2. How do the authors explain that only slightly more than half of the residents (54%) even included something as basic as the date of delivery? Does this not imply an inherent lack of understanding of the documentation process or study bias?

3. The majority of the "key" delivery note components identified by the authors are most likely already contained within some other area of the medical record and therefore are not truly essential to the delivery note. With regard to the listed reference² from which the authors have compiled the "recommendations," they seem to have forgotten these salient documentation points:
a. Why and how dystocia was diagnosed
b. Progress of labor (active phase and second stage)
c. Position and rotation of the infant's head
d. Presence of episiotomy, if performed
e. Estimation of force of traction applied
f. Order, duration, and results of maneuvers employed
g. Presence of neurologic and/or bone injury

4. Finally, we are concerned that the authors are not only setting a new standard for documentation but that they believe that better documentation is "essential" for better patient care. How does the identification of the anterior shoulder at the time of delivery have anything to do with the care and treatment of a brachial plexus injury during the neonatal period? How do the authors conclude that the head-to-body interval is "necessary documentation in the event that a lawsuit is brought against the physician" when it has been shown that this interval is not related to umbilical artery pH, Pco₂, base deficit, or decreasing 5 minute Apgar score?³

doi:10.1097/01.AOG.0000153263.08330.2c

REFERENCES

1. Deering S, Poggi S, Hodor J, Macedonia C, Satin AJ. Evaluation of residents’ delivery notes after a simulated shoulder dystocia. Obstet Gynecol 2004;104:667–70.[Abstract/Free Full Text]

2. Acker DB. A shoulder dystocia intervention form. Obstet Gynecol 1991;78:150–1.[Abstract/Free Full Text]

3. Stallings SP, Edwards RK, Johnson JWC. Correlation of head-to-body delivery intervals in shoulder dystocia and umbilical artery acidosis. Am J Obstet Gynecol 2001;185:268–74.[Medline]

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