Shoulder Dystocia Documentation: Implementing a Protocol

Pamela Willis, BSN, JD, Patient Safety Risk Manager II

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 provided. 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.

The Doctors Company reviewed closed shoulder dystocia claims that occurred between 2014 and 2018. We identified poor documentation as a factor in 46 percent of the cases.

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 pounds 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 a suit against the physician for improper management of delivery.

The medical record showed the physician had documented that a dystocia had occurred, but he did not elaborate on the maneuvers used to accomplish delivery or on the degree of ease or difficulty in carrying out the maneuvers. The record did not include 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 documentation can differ from nursing documentation, 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 based on standardized forms or checklists 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, in its Committee Opinion 680, has recommended the use of standardized forms or checklists to aid in documenting emergent events. 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 prompt the provider to incorporate 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.

Once the appropriate committee in your facility has agreed on a tool to use for shoulder dystocia documentation, the committee and the risk department 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. A standardized documentation tool and protocol could make a critical difference if you are called to defend your care.

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