Difficult Deliveries and Shoulder Dystocia

Dictate or write a detailed summary of all difficult deliveries or those associated with neurological deficit or low Apgar scores. For deliveries associated with shoulder dystocia and neurological deficit or fractures, detail the circumstances and maneuvers performed and frankly discuss the situation with mother. When dealing with shoulder dystocia, focus primarily on the shoulders and not the vertex. There is no one maneuver or sequence of maneuvers that is superior. It is a good idea to have a mental drill periodically in anticipation of shoulder dystocia.

Document time of decision and fetal station at application of vacuum or forceps. Involve the patient with difficult delivery decisions. When risks are relatively balanced between one option and another, it may take some pressure off the physician and promote more ownership by the patient (see appendix).

Placental Pathology

Detailed analysis of the placenta can help significantly in determining the presence of antepartum factors related to poor outcomes and is underutilized in general. A liberal policy is recommended for requests for pathology on the placenta that may include the following conditions, depending on the circumstances. The important message here is that a pathological condition can often explain a bad outcome and improve future patient care and education.

Maternal conditions: severe diabetes, hypertensive disorders, collagen vascular disease, premature delivery, peripartum fever, postpartum hemorrhage, maternal HIV infection or other infectious disease, severe oligohydramnios, unexplained fetal death, abruption, thick meconium, history of substance abuse, severe polyhydramnios, heavy smoking.

Fetal conditions: stillbirth, cord ph <7.0, Apgar <6 at 5 minutes, birthweight < 10th percentile, multiple gestations, dysmorphic appearance, and abnormal-appearing placenta.

Hospital Chart Documentation

• Chart discrepancies or disagreement objectively and without inflammatory remarks. Document patient refusal of recommended care
  
  
• Date and time notes
  
  
• Explain pertinent factors and decisions
  
  
• Avoid criticism of other doctors involved in the patient's care in the medical record
  
  
• Document station and time prior to operative delivery
  

Office Records

• Record action taken due to abnormal studies
  
  
• Use a tracking system that accounts for patients who need follow-up studies, procedures, or consultations
  
  

Appendix

Conversation About Potential Shoulder Dystocia

Shoulder dystocia is unpredictable. At the same time, be hypervigilant with EFWs of more than 4000g and watch out for babies of gestational diabetics and those with history of macrosomic babies. The most prudent care and most careful delivery will not prevent all brachial plexus injuries. Even the most skilled and seasoned obstetricians may perform a delivery associated with permanent injury.

Example of Conversation: "Ms. Smith, I have a feeling that you are carrying a larger-than-average baby. Even with further testing, I could not be completely certain of your baby's size, and there are factors such as your internal anatomy that affect the delivery. The worrisome part about this situation is that the head may deliver and the shoulders not follow despite proper techniques. It is impossible to accurately predict shoulder dystocia. It is perfectly acceptable to continue with labor, be ready for special maneuvers, and do my best to prevent injury to the shoulder or nerves supplying the arm. Delivery can be forceful and associated with permanent injury at times, although permanent injury is fairly uncommon."

Example Note: "I have discussed my concerns with the patient regarding the potential for severe shoulder dystocia. Ms. Smith understands the unpredictable nature of shoulder dystocia and stated that she would like to proceed with vaginal delivery."

Example Note: "The patient was informed of the risks of shoulder dystocia. She mentioned that she has a relative who had a baby with permanent injury and that her last baby weighed 9 1/2 pounds. The patient would rather accept the risks of cesarean section, which we discussed, than to proceed with vaginal delivery."

Page 1: Fetal Monitoring and Related Delivery Decisions
Page 2: Important Facts about Cerebral Palsy
Page 3: Oxytocin, History of Cesarean Section/VBAC, Group B Streptococci Carriers
Page 4: Shoulder Dystocia, Placental Pathology, Documentation & Records