Improvement in documentation using an electronic checklist for shoulder dystocia deliveries

Obstet Gynecol. 2010 Jul;116(1):63-66. doi: 10.1097/AOG.0b013e3181e42220.

Abstract

Objective: To estimate if using an electronic checklist improved the documentation of shoulder dystocias that occurred at our institution.

Methods: A standard checklist of key elements that should be included in the delivery note after a shoulder dystocia was added to the electronic delivery note at our institution. We identified shoulder dystocia deliveries from the department's delivery database for 3 years before and after the checklist was included and compared delivery notes written from these time periods with respect to their content.

Results: Forty-six shoulder dystocia deliveries were identified before the checklist being available and 82 after. There was a significant increase noted in the frequency with which several elements were documented after the checklist was implemented including McRoberts maneuver (before checklist 69%, compared with after checklist 90%, P=.003), head-to-body interval (22% compared with 84%, P<.001), which shoulder was anterior (48% compared with 96%, P<.001), and if the neonate was moving its arms after delivery (50% compared with 93%, P<.001).

Conclusion: Use of a standard checklist for shoulder dystocia in the delivery note resulted in a significant improvement in the documentation of several critical elements.

Level of evidence: II.

MeSH terms

  • Checklist*
  • Documentation / methods*
  • Dystocia / epidemiology*
  • Electronics
  • Female
  • Humans
  • Pregnancy
  • Shoulder