title: Documentation of instrumental vaginal deliveries: The benefits of a pro forma.
abstract: BACKGROUND
  Instrumental vaginal deliveries (IVDs) account for approximately 11% of births in Australia. Complications resulting from IVD can occasionally be the subject of litigation. The Royal College of Obstetricians and Gynaecologists suggests a standardised pro forma in their guidelines as an aid to accurate and complete IVD documentation. Many units, including ours, use less structured reporting, which is probably also less adequate.
  
  
  OBJECTIVE
  To assess whether the introduction of a dedicated IVD form improves the quality of IVD documentation.
  
  
  METHODS
  Analysis of the quality of IVD documentation before and after the implementation of a new dedicated IVD form. A survey to evaluate clinicians' opinion on the new standardised form.
  
  
  RESULTS
  Significant improvement was found in documentation of key information including the documentation of caput (p < 0.05), type of instrument, number of ventouse cup detachments, moulding of specific sutures, abdominal palpation (number of fifths of foetal head palpable), liquor colour and total time of instrument application (p < 0.001). A majority of clinicians believed the form to be beneficial in terms of completeness and that it reduced the amount of time required for documentation.
  
  
  CONCLUSIONS
  IVD documentation is enhanced by the use of a dedicated form. Clinical judgement may also be enhanced by the discipline involved in the formal assessment required by the form.
authors.affiliation: Women's and Newborn Health Division, Westmead Hospital, Sydney, Australia aiat.shamsa@gmail.com.
authors.forename: Aiat
authors.initials: A
authors.lastname: Shamsa
authors.affiliation: Women's and Newborn Health Division, Westmead Hospital, Sydney, Australia.
authors.forename: Agnes Jy
authors.initials: AJ
authors.lastname: Jang
authors.affiliation: Women's and Newborn Health Division, Westmead Hospital, Sydney, Australia.
authors.forename: Therese M
authors.initials: TM
authors.lastname: McGee
mesh_terms: D001315:Australia; D036861:Delivery, Obstetric / Q000295:instrumentation*; D004282:Documentation; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008505:Medical Staff, Hospital / Q000523:psychology; D061214:Patient Safety; D011247:Pregnancy; D011787:Quality of Health Care; D011795:Surveys and Questionnaires
keywords: documentation; evaluation; medical devices; obstetric delivery; procedures