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Letter to the Editor |
In Reply:
We appreciate the opportunity to respond to and clarify some of the issues raised in their letter by Drs. Gherman and Chauhan.
The reasons that not all residents participated in our study was addressed in a previous publication that is referenced in the paper. Under Materials and Methods, the second paragraph states, "The details of resident performance in this simulation exercise have been previously described." Indeed, Dr. Gherman was a coauthor of this paper.1 The excluded residents were postcall (n = 5), on a night float rotation and unavailable (n = 4), or on vacation (n = 3). With regard to the second concern that only 54% of residents included the date of delivery, we feel that there are at least two plausible explanations for this. First, there is always the drawback to simulation that residents may not treat the situation as completely "real," and this may be reflected in their notes. Second, many of these residents rotate to hospitals where all medical records are electronic and are automatically given a time and date stamp when stored. Even if this second reason holds, however, the backup plan is to use handwritten forms should the electronic records be unavailable secondary to system problems, so it does not obviate the need to pay attention to this detail.
As we stated in our paper, the 15 components for our list were derived from both the reference by Acker et al,2 as well as through consultation with three separate staff physicians. They were not just derived from a single source as suggested in their letter. In addition, some of the "salient documentation points" that Dr. Gherman and Dr. Chauhan feel we omitted are actually covered in the list we used. These include the position of the infant's head, as this is implied by which shoulder is anterior, the presence of episiotomy, which is included under "all maneuvers used" as it was considered one of the accepted interventions, and the order of maneuvers utilized was also one of our criteria. The status of the infant's extremity is addressed as well in that residents were expected to note that the infant was moving all extremities after delivery. While this does not definitively diagnose a neurologic injury, we feel that this is a reasonable degree of documentation to include when the initial delivery note is written just after delivery, with additional details added later as the pediatricians have more time to evaluate the infant.
We chose not to include the estimation of force of traction applied in our evaluation because we are not convinced that the answers given could be objectively determined. If a resident wrote that he or she applied "minimal" traction, but review of the resident's videotaped session revealed that more than this was subjectively applied, then it would be difficult to grade. While we agree that noting how much force was applied is a reasonable thing to include in the delivery note, we have never seen anyone write anything other than "appropriate," "moderate," or "minimal," with respect to how much force was applied and have certainly never seen anyone document that "excessive" traction was applied.
In addition, while we also acknowledge that the head-to-body interval is not necessarily indicative of fetal compromise, the fetal pH has been estimated to fall 0.04 pH units per minute between delivery of the fetal head and trunk.3 And, although there is no objective evidence for this, we believe it may be easier for a jury to have a head-to-body interval recorded, which may be quite short and reasonable, rather than to have nothing in the record and allow them to speculate.
With regard to the author's concerns that we are setting a new standard for documentation, this is an understandable, but unfounded concern. We specifically stated in our article that "The use of the delivery note and feedback regarding the note provide a simple and potentially important addition to the simulation teaching models that allows instructors to identify deficiencies in documentation" and that "additional research into techniques to improve documentation with this tool should be pursued."4 The focus of this report was resident education. While we certainly do not hold out our list of delivery note components as the "standard of care" by any means, we feel that the only people who will benefit from not improving resident's documentation in their delivery notes are the plaintiff's lawyers and their expert witnesses.
doi:10.1097/01.AOG.0000153369.42947.4c
REFERENCES
1. Deering S, Poggi S, Macedonia C, Gherman R, Satin AJ. Improving resident competency in the management of shoulder dystocia with simulations training. Obstet Gynecol 2004;103:1224–8.
2. Acker DB. A shoulder dystocia intervention form. Obstet Gynecol 1991;78:150–1.
3. Wood C, Ng KH, Hounslow D, Benning H. Time: An important variable in normal delivery. J Obstet Gynaecol Br Commonw 1973;80:295–300.[Medline]
4. 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.
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