Chart documentation of informed consent for operative vaginal delivery: is it adequate?
OBJECTIVE
To determine the documentation frequency of informed consent for women undergoing a trial of nonemergent instrumental delivery.


METHODS
A retrospective chart review of instrumented vaginal deliveries from 1992 to 2005 was performed. Cases were identified from a Labor and Delivery database and hospital records were reviewed for documentation of associated risks, general consent for the procedure, indication, and option of cesarean delivery (CD).


RESULTS
Three hundred forty six charts were reviewed: 246 were excluded for an emergency delivery (19%), misclassification (25%), or lost notes (27%). In the remaining 100 cases, 61% had a general consent for instrumented vaginal delivery. Documentation of any maternal or neonatal risks was found in 3% and 0%, respectively. The option of a cesarean delivery was documented in 22% of the cases. When comparing 5-year time intervals before and after 2000, there was no increased frequency in documentation of maternal or neonatal risks.


CONCLUSIONS
Documentation of informed consent for instrumented vaginal delivery is inconsistent and should be improved.
Nichols
Catherine Matthews
CM
Department of Obstetrics and Gynecology, School of Medicine, Medical College of Virginia/Virginia Commonwealth University Medical Center, Richmond, VA, USA. cmnichol@hsc.vcu.edu
Pendlebury
Laura C
LC
Jennell
Jamie
J
D032962:Consent Forms; D036861:Delivery, Obstetric / Q000379:methods; D005260:Female; D006801:Humans; D007258:Informed Consent; D009772:Obstetrical Forceps; D011247:Pregnancy; D012307:Risk Factors; D014219:Trial of Labor; D014620:Vacuum Extraction, Obstetrical