Documentation of simulated shoulder dystocia: accurate and complete?
OBJECTIVE
To investigate completeness and accuracy of record keeping by comparison of documentation and actual events, recorded on video and through a force-monitoring device, during simulated shoulder dystocia.


METHODS
An observational study.


METHODS
Six maternity units in South West of England.


METHODS
Seventy-one midwives and 39 doctors.


METHODS
Doctors and midwives documented their management of a shoulder dystocia simulation on paper used in their hospital (simple notepaper or preformatted form). Documentation was compared with video recording of each simulation and an electronic record of force applied during delivery.


METHODS
Documentation of head-to-body delivery time (and comparison with actual delivery time). Documentation of force (and comparison with actual applied force).


RESULTS
A total of 110 participants documented their actions, 70.9% used a preformatted sheet, 29.1% used hospital notepaper. Fifty-six percent documented head-to-body delivery interval (HBDI) with 56% overestimating the time by more than 1 minute. Force used during the simulation was documented by 70.9%, with no relationship between the subjective description of force applied and the maximum recorded force. The anterior shoulder was documented by 78.2% and correctly identified in 80%. Documentation of force was more likely if a preformatted sheet was used (88 versus 53%, P = 0.016). Documentation of the laterality of the anterior shoulder was tended to be more accurate with plain hospital notepaper (93 versus 78%, P = 0.3526).


CONCLUSIONS
Manoeuvres performed were well documented. HBDI and force applied were not documented accurately in the majority of simulated deliveries. Use of a preformatted sheet appeared to improve completeness, but not accuracy, of documentation.
Crofts
J F
JF
The SaFE Study, Department of Obstetrics and Gynaecology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK. jocrofts@doctors.org.uk
Bartlett
C
C
Ellis
D
D
Fox
R
R
Draycott
T J
TJ
D036861:Delivery, Obstetric; D004282:Documentation / Q000592:standards*; D004420:Dystocia / Q000175:diagnosis*; D005260:Female; D006801:Humans; D007746:Labor Presentation; D008499:Medical Records / Q000592:standards; D011247:Pregnancy; D012782:Shoulder