Decreasing Liability of Shoulder Dystocia

  • Indeed the obstetric complication, should dystocia (SD) is unpredictable and unpreventable. This being true, why is shoulder dystocia among the top four in frequency of malpractice lawsuits (the other three are “fetal distress, uterine rupture following trial of labor after cesarean, and misdiagnosis of breast cancer) Pubmed search.
    Discussion here is intended for obstetric professionals that are quite familiar with diagnosing and managing shoulder dystocia. This is not intended to be a review of such topics, but rather a clinician-to-clinician discussion of why do we face liability concerns with an unpredictable and unpreventable clinical condition even when properly managed.
    What our legal counsel/advisors typically point out are documentation concerns when faced with defending a complication of shoulder dystocia. Importantly, when it comes to documentation, the unhelpful adage, “if it isn’t documented it wasn’t done” can lead to a fatalistic sense of “I certainly cannot document everything I’ve done, so why even attempt”. To those who ascribe to this adage of “what’s not documented wasn’t done”, I would challenge with the question, how often to you document the words “I provided compassionate, and competent care to this patient”? I suspect it is rare if at all that one documents words to this effect, yet I am certain that (excellent care)is what most, if not all, of us do.
    Additionally since shoulder dystocia is such an emergency, an emergency that cannot be predicted, indeed time is of the essence, and spending time documenting detracts from the time spent properly and efficiently managing the complication. Most of us have had the sense that during such an emergency, a second feels like a minute, and spending even three seconds assuring good documentation, feels like wasting such precious time.
    So what does one do!?
    In the same manner that most of us have drilled (both in real practicums on the L&D unit as well as virtually in our heads) on the management of shoulder dystocia, we should drill on documentation. This is important even understanding the sentiment that many of us might have that “I’d rather have excellent efficient management of SD and horrible documentation, than that opposite”.
    Before getting to a suggested documentation practice, let’s make clear what the challenges to documentation include:

The person documenting on the nursing side of the ledger is likely the nurse assigned to the patient. This nurse is likely your first and most important (since this nurse is the immediately available in this “time is of the essence” situation). This nurse is likely the person applying suprapubic pressure and is not to be stopped to begin documentation.

In some smaller units e.g., some rural hospitals, or even in larger units that are understaffed, there are instances where the only humans (other than patient and visitors) in the room is one nurse and one tech. Which of those are you going to have stop assisting with delivery to document!?
Even in instances where there are many hospital staff in the room yielding the luxury of assigning a “scribe”, that person may not have medical/obstetric terminology as a strength and terms such as “Gaskins” or “Menticoglou” may be completely missed.
So here are a few recommendations:
Of course, as always with SD, call for help. When there are healthcare workers in the room that are not involved with hands on the patient, maintaining McRoberts and suprapubic pressure and such, first assign a timer to call out “30 seconds, 60 seconds, …, then a scribe to take notes of what you will call out and do so in order. These notes won’t be the final documentation in the medical record, but what will be used such that the provider and nurse can coordinate their documentation.
Once the delivery is completed, the nurse and delivering professional should meet and document in separate notes based on memory aided by the handwritten notes of the scribe.
In instances where there is no personnel that can take the role of scribe, then still the nurse and provider should coordinate their notes. Understand, this is not collusion to cover some poor practice. Indeed, if someone believes that fundal pressure was applied during management of SD, then that is a whole other matter that is beyond our discussion here. But if, for example, the physician documents that suprapubic pressure was applied, then an attempt to deliver the posterior shoulder, but the nurse documents the opposite order, this is how good and appropriate management looks not-as-good.
Adding these two tools (timer and scribe) and a coordinated documentation adds little time to the otherwise efficient management of SD, and in instances where SD leads to a poor outcome, leads to a better presentation of the clinician’s excellent management of an unpredictable complication. It should take no more than literally two seconds to assign these roles.

While we again, restate the un-preventability of Shoulder Dystocia, we will follow in upcoming discussions of management of risk factors. Stay Tuned!

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