title: [Shoulder dystocia: Quality of retranscription in medical files].
abstract: OBJECTIVE
  Shoulder dystocia is a rare obstetrical event and potentially serious. Apart from possible psychological implications, it may be responsible for maternal (haemorrhage and perineal tear) and neonatal complications (brachial plexus) leading to complaints and even lawsuits. The transcription of this event in medical files is essential as it is a reflection of the work in an emergency. It allows the obstetrician to defend him in case of trial. Our objective was to assess the quality of the transcription of shoulder dystocia situations in medical files.
  
  
  METHODS
  Retrospective chart study conducted in a university hospital with maternity type III. The primary objective was the rate of comprehensive records (name maneuvers and order of maneuvers of the anterior shoulder hand, time between the expulsion of the head and body, Apgar score).
  
  
  RESULTS
  Between 2007 and 2015, 54 cases of shoulder dystocia requiring a second line maneuver after vaginal delivery (Wood and/or Jacquemier) were included. In all, 98.2% of the files were incomplete. The maneuvers and their order were noted in 100% of cases. However, the operation was not correctly described in 16.7% of cases. The anterior shoulder was noted in 16.7% of cases. The time between the expulsion of the head and the body was noted in one single files. Neither broken collarbone nor brachial plexus were observed.
  
  
  CONCLUSIONS
  To improve the management of dystocia shoulder and transcription of data in files, simulation sessions and the creation of a standardized form would be needed.
authors: Service de gynécologie-obstétrique, CHU d'Angers, 4, rue Larrey, 49033 Angers cedex, France. Electronic address: emmanuellemartin85@free.fr.
authors: E
authors: E
authors: Martin
authors: Service de gynécologie-obstétrique, CHU d'Angers, 4, rue Larrey, 49033 Angers cedex, France. Electronic address: pebouet@hotmail.com.
authors: P-E
authors: PE
authors: Bouet
authors: Service de gynécologie-obstétrique, CHU d'Angers, 4, rue Larrey, 49033 Angers cedex, France. Electronic address: LoSentilhes@chu-angers.fr.
authors: L
authors: L
authors: Sentilhes
authors: Service de gynécologie-obstétrique, CHU d'Angers, 4, rue Larrey, 49033 Angers cedex, France. Electronic address: g_legendre@hotmail.com.
authors: G
authors: G
authors: Legendre
mesh_terms: D000328:Adult; D001720:Birth Injuries / Q000209:etiology; D001917:Brachial Plexus / Q000293:injuries; D036861:Delivery, Obstetric / Q000331:legislation & jurisprudence; D004420:Dystocia / Q000628:therapy; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008499:Medical Records / Q000592:standards*; D011247:Pregnancy; D012189:Retrospective Studies; D012782:Shoulder
keywords: Documentation; Dystocie des épaules; Protocol; Protocole; Shoulder dystocia; Simulation