Shoulder Dystocia Documentation: Implementing a Protocol in Your Facility

Pamela Willis BSN, JD, Patient Safety Risk Manager.

When reviewing malpractice claims in the obstetric arena, shoulder dystocia situations have traditionally been among the most problematic to defend. It may be difficult for the layperson on a jury to understand that a brachial plexus injury can occur even when the best possible care is given. Another problem compounding the defense of shoulder dystocia cases is a lack of detailed documentation of the event. In such circumstances, missing data may erroneously be supplied by nonmedical personnel in attendance at the delivery or must be assumed by expert witnesses on either side.1

The Doctors Company reviewed closed shoulder dystocia claims that occurred between 2007 and 2014. Thirty-five percent of the cases were identified as having poor documentation.

Case Study

A gravida 5, para 4 patient presented to the labor and delivery unit. She was 5 feet 5 inches tall and weighed 210 lbs at 39+3 weeks’ gestation. Her labor progressed well, but a dystocia occurred during shoulder delivery. An 8 pound, 15 ounce infant was delivered with bruising noted on the shoulder and decreased movement of the right arm observed. The infant was subsequently diagnosed with Erb’s palsy and at 13 months had very little use of the right arm. The parents brought suit against the physician for improper management of delivery.

The medical record showed the physician had documented that a dystocia had occurred but did not elaborate on the maneuvers used to accomplish delivery or the degree of ease or difficulty in carrying out the maneuvers. There was no nursing documentation on the use of maneuvers. The physician’s testimony at deposition was that he had the nurses perform the McRoberts maneuver and apply suprapubic pressure. He stated that he was then able to deliver the posterior arm and free the shoulder, delivering the infant.

The plaintiff’s expert felt that the shoulder bruising was evidence of excessive force and traction. The defense expert was supportive of the physician’s testimony. However, due to a lack of documentation of the events that transpired, the case was difficult to defend.

Across healthcare teams, documentation of high-risk events often contains inconsistencies. The provider’s chart notes can differ from nursing chart notes, creating an adversarial relationship within the healthcare team and causing credibility issues for those later involved in litigation over the event. For this reason, we recommend a system of collaborative charting for all high-risk events.

Collaborative charting relies on a conversation between the bedside nurse(s) and the delivering provider to correctly recall the quickly moving events that took place during the emergency. Because each person involved in a medical emergency can be fixated on his or her individual tasks, recollections of all events may be unclear. Reassembling the healthcare team immediately after the event to review the emergent actions taken can assist in proper, collaborative recollection and accurate documentation by all parties.

The American College of Obstetricians and Gynecologists has recommended the use of standardized forms or checklists when documenting a shoulder dystocia delivery.2 A standardized form can help ensure documentation of all important areas and serve as a tool for nursing staff to assist in documenting critically important times and actions as they occur during the event.

A standardized shoulder dystocia tool should include prompts for the provider to include specific information in his or her note on the delivery. The tool should include the following information:

  • Patient history and risk factors that are pertinent to shoulder dystocia.
  • Maneuvers and instrumentation used to accomplish delivery.
  • Times of important points in the delivery (onset of second stage, delivery of the head, delivery of the shoulders, etc.).
  • Information on the condition of the newborn at delivery may also be helpful.

Once the appropriate committee in your facility has agreed on a tool to use for shoulder dystocia documentation, the committee should decide how it will be used. Will it be a tool for nursing staff to assist in recording events in real time, similar to a code blue documentation sheet? Will it become part of the permanent medical record? Will your risk management department retain the tool as part of its quality review activities?

Regardless of how your facility decides to use a standardized documentation tool, make sure that nursing staff can access it quickly during a shoulder dystocia emergency to capture correct information with real-time documentation. After the event, reassemble the healthcare team to review the form collaboratively before each party creates permanent documentation. Establishing this kind of policy can ensure a truly accurate description of events in the medical record.

To provide the best possible defense, it is essential that the healthcare team accurately and thoroughly document the events of a shoulder dystocia emergency. Consider working with the obstetric committee and risk department in your facility to implement a standardized documentation tool and protocol. Doing so could make a critical difference one day if you are called up to defend your care.


  1. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008 Dec;112(6):1279-1283.
  2. American Congress of Obstetricians and Gynecologists. Optimizing Protocols in Obstetrics Series 3. July 2013. 

Additional Resource

Patient safety checklist: documenting shoulder dystocia. American Congress of Obstetricians and Gynecologists Website.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J10205 07/15

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