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Delivery record key after shoulder dystocia: consider dictating notes.

MAUI, HAWAII -- Put plenty of details in the delivery record of a baby injured due to shoulder dystocia to avoid a lawsuit, two attorneys advised at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

"Even if you do everything right, if you do not have a detailed delivery record, you'll be lost when you get to court," said Norman D. Tucker, J.D., a plaintiff's lawyer in Southfield, Mich.

Approximately 5% of suits against obstetricians involve shoulder dystocia. Mr. Tucker, who has been in practice for 20 years, said he has never seen a legal case involving shoulder dystocia that included a detailed delivery note. "So either the physicians are not doing them, or the ones who do never get to litigation," he said.

The unreliability of the mother's recall of labor events highlights the importance of the medical documentation, added Robert R Roth, J.D., a defense lawyer in Bloomfield Hills, Mich. A recent study of 277 women who were interviewed a median of 10 weeks after delivery found that 60% could not recall accurately at least one of the major management events (such as use of forceps) in their labor); only 40% answered all questions correctly (Am. J. Obstet. Gynecol. 189111:195-200, 2003).

Most physicians sense within minutes of delivering an injured child that a lawsuit is probable Documentation is the key to defense, Mr. Roth said at the meeting, sponsored by Boston University and the Center for Human Genetics.

Be prepared in advance for shoulder dystocia (through practice drills, having enough help in the delivery room, and keeping backup help ready) but don't neglect making a detailed record afterward.

If you feel compelled to make a correction in the record later, follow the accepted protocol of crossing out the portion to be changed, writing the new portion, and signing your initials with the date and time, he added. If a lawsuit is filed, avoid further changes but consider creating a memo of additional recollections.

Faulty delivery records sometimes minimize the existence of shoulder dystocia in a delivery by claiming it wasn't really shoulder dystocia, Mr. Tucker said. Abbreviated notes are not helpful, listing only the procedures performed without any information about when the maneuvers were done, by whom, for how long, results of each maneuver, whether and when there were attempts at gentle downward traction, the rationale for different maneuvers, or other details. Abbreviated notes put the physician in the position of being the only one who knows what he or she did and having to explain the details later.

The American College of Obstetricians and Gynecologists recommends that physicians consider dictating rather than writing a detailed obstetric delivery note, especially after an instrumental delivery. Surgeons customarily dictate notes after even the simplest of operations, and obstetricians should make it a habit after deliveries as well, Mr. Tucker said.

'Foundational Facts'

Plaintiffs' lawyers look for these "foundational facts' in the delivery record or gather the facts themselves in shoulder dystocia cases, Mr. Tucker said:

* How many people were in the room?

* Where was each person? Where did they move?

* Were the mother's feet ever out of the stirrups? (Necessary to attempt the McRoberts maneuver.)

* Did anyone have their hands on the mother's legs? Who? When?

* Did the physician instruct specific nurses to take the mother's legs, or

* Did a nurse tell the father to grab one?

* How high was the bed? (Perhaps too high to apply suprapubic pressure.)

* Did anyone push on the mother's abdomen? Where?

* Which way did the baby face when the head emerged? (The anterior shoulder is most often injured,)

* How much time elapsed from delivery of the fetal head to delivery of the body?

* What was the position of the physician's hands and body?

* Who said what?


San Francisco Bureau
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Title Annotation:Obstetrics
Author:Boschert, Sherry
Publication:OB GYN News
Date:Feb 15, 2004
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