Shoulder Dystocia, April 2008
Dictation/documentation template
SHOULDER DYSTOCIA
ALL deliveries complicated by shoulder dystocia should be dictated into
Careweb. In order to assure completeness of the dictation, please use this
template.
Pre-operative diagnosis:
Post-operative diagnosis:
Procedure:
Anesthesia:
Attending MD:
Resident physician:
Indication:
Describe labor progress, review of fetal heart tones, risk factors
for shoulder dystocia, diagnosis of shoulder dystocia.
Procedure:
Shoulder dystocia;
- Call for assistance
- McRoberts maneuver, describe instruction to nursing
- Evaluation/extension of episiotomy
- Suprapubic pressure, describe instruction to nursing
- Wood's screw maneuver, describe which shoulder is anterior, direction of rotation
- Delivery of posterior arm
- Zavenelli procedure
Third stage;
- Delivery of placenta
- Findings of episiotomy and extensions
- Description of repair
- Estimated blood loss
- Verification of needles and sponges
- Cord gasses and placenta were sent
Describe findings on baby and resuscitation.
An example of description follows on next page:
Shoulder Dystocia, April 2008
Example of Shoulder Dystocia Documentation
Pre-operative diagnosis:
Shoulder dystocia
Post-operative diagnosis: Shoulder dystocia,
resolved after delivery of the posterior arm,
midline episiotomy with 3rd degree extension.
Procedure:
McRoberts maneuver, right medio-lateral episiotomy,
Supra-pubic pressure, Woodscrew maneuver,
Delivery of posterior arm.
Anesthesia:
Epidural
Attending MD:
Name and physician number
Resident physician:
Name and physician number
Indication:
Ms Johnson is a 32 year, G1P0, edd 10-19-2006, estimated gestational age 40 0/7 weeks.
Labor course was uneventful; length of second stage was 2 hours and 10 minutes. Fetal
heart rate strip was reviewed and assessed as reassuring. After delivery of the fetal head
we were unable to deliver the anterior shoulder by applying moderate downward motion.
The diagnosis of shoulder dystocia was made.
Procedure:
The patient and her family as well as the birth attending staff were informed.
The nurse and resident were instructed to proceed with the McRoberts maneuver; delivery
of the anterior shoulder was unsuccessful.
A right mediolateral episiotomy was cut.
The nurse was instructed to proceed with supra-pubic pressure; again delivery of the
anterior shoulder was unsuccessful.
The back of the fetus was on the maternal left side. The Woodscrew maneuver was then
attempted, the anterior shoulder was on the maternal left, but we were unable to rotate the
anterior shoulder in a counter clock wise fashion.
The posterior arm was carefully delivered over the fetal chest and maternal perineum. By
doing so the anterior shoulder delivered underneath the symphysis pubis.
The remainder of the infant was delivered, umbilical cord clamped and cut, and the infant
handed over to the pediatricians.
The perineum revealed a right mediolateral episiotomy with a third degree extension.
This was repaired in layers using 3-0 Vicryl suture.
Cord gasses and cord bloods were obtained.
The placenta was delivered spontaneously, complete and intact and send to pathology.
Shoulder Dystocia, April 2008
Estimated blood loss during the procedure was 400ml.
Sponge and needle counts were correct at the completion of the procedure.
Apgar scores were 3 at 1 minute, 6 at 5 minutes and 9 at 10 minutes.
There was no evidence of bruising on the babies head.
There was clinical evidence of a fracture of the right clavicle.
Movement of both arms and hands were normal and symmetric.