A survey of fellows of The American College of Obstetricians and Gynecologists revealed that 76% have had at least one professional liability claim filed against them.1
Nearly 30% have had one or more claims related to care given during residency. Accordingly, residents in training must be aware of clinical events that lead to malpractice claims and develop strategies to minimize claims. The educational objectives published by the Council on Resident Education in Obstetrics and Gynecology includes thorough documentation of patient encounters and procedures as part of a systematic plan to minimize the risk of malpractice claims.2
We have included birthing simulation in our residency-training curriculum in an effort to improve clinical skills in the management of shoulder dystocia. Because fetal injury related to shoulder dystocia is a potential source of liability claims, we wondered whether a simulation curriculum could be expanded to identify deficiencies in medical documentation and ultimately educate residents about how to reduce liability risk while improving clinical care. Specifically, the objective of this study was to describe and analyze delivery notes after a shoulder dystocia case by using a standardized scenario with an obstetric birth simulator where actual times and outcomes were known.
MATERIALS AND METHODS
A total of 33 residents from 2 separate residency programs underwent training and testing with a standardized shoulder simulation scenario using an anthropomorphic female birthing simulator. This investigation was performed in accordance with the guidelines of the institutional review boards of both Georgetown University Hospital and the Uniformed Services University of the Health Sciences.
The details of resident performance in this simulation exercise have been previously described.3 Briefly, the exercise began before entering the room for testing. Residents were given a clinical scenario to review that informed them they were about to meet a 35-year-old multiparous patient who had been pushing for approximately 90 minutes with an epidural and whose only prenatal complications included advanced maternal age and an abnormal 1-hour glucose tolerance test with a normal follow-up 3-hour test. The residents were told to treat the situation as realistically as possible and to use instruments, gloves, or whatever else they felt they needed, just as in a real labor and delivery room. They were not told that they would be required to write a delivery note at the end of the procedure. Upon entering the laboratory, one assistant playing the role of the nurse told the resident the patient was pushing well and then the fetal head was made to deliver in the occiput anterior position. When the resident applied downward traction to the head for delivery of the anterior shoulder, a dystocia was simulated by a harness around the fetus that was controlled by the testing staff but was not visible to the resident because it was located inside the abdomen, which prevented the fetus from delivering. Additional assistants, playing the roles of a second nurse and a pediatrician, were available in the room and assisted if the resident specifically asked for their help. The residents were then monitored by the testing staff, and the infant was allowed to deliver if the resident successfully delivered the posterior arm. If the resident could not or did not attempt to deliver the posterior arm, then the scenario was stopped, either when a Zavenelli maneuver was performed or when the resident said that he or she did not know any other maneuvers to accomplish delivery. After the scenario ended, each resident was told the infant's weight and Apgar scores and that the infant was moving all extremities. They were also asked to estimate how long the head-to-body interval was during the delivery. The resident was then taken to a separate room, given a blank progress note, and asked to write a delivery note for the delivery just performed. All testing was videotaped for evaluation.
The delivery notes were collected and evaluated for the presence or absence of 15 important components. These included the date and time of the delivery, identification of anterior shoulder, infant birth weight, all maneuvers used, Apgar scores, and the presence of pediatrics at the delivery, as well as other components listed in the box. These criteria were compiled from previously published recommendations and after consultation with 3 separate staff physicians.4 The delivery notes were compared with the videotaped sessions to determine whether all maneuvers used were contained in the notes and whether they were in the correct order. The Student t test was used to determine whether there was a significant difference in scores between the 2 institutions. P < .05 was considered significant. Descriptive statistics were calculated that included determination of the number of items reported as well as the percentage of residents who reported each specific component in the delivery note.
Evaluation List of Delivery Note Components
Date of delivery
Time of delivery
All providers present at delivery
Classifies complication as shoulder dystocia
Notes which shoulder was anterior
Notes how long it took to deliver the shoulder
Notes infant birth weight
Notes Apgar scores
Notes if cord gases sent
Mentions that infant is moving all extremities after delivery
Notes pediatrician called for delivery
Includes estimated blood loss
Includes all maneuvers used
Includes correct order of maneuvers used
Notes patient had epidural anesthesia
Table 1 shows residents’ mean scores by institution and level of training. There was no difference in the mean scores between the 2 sites (P = .26, 95% confidence interval –2.91–0.83). Figure 1 shows the distribution of scores with regard to the fifteen key components included in the residents’ delivery notes. The highest score achieved was 12 out of 15, by 3 of 33 residents. The lowest score was 3 of 15, by 2 residents. The median score was 8 out of 15, and the mean number of items included in the delivery notes was 7.5 (±2.7). Seventy-six percent (25/33) of residents recorded fewer than 10 of 15 key components. Table 2 lists the 15 key components and shows the percentage of residents who recorded each particular component. The elements most commonly recorded were Apgar scores, the providers present at delivery, a correct list of all maneuvers use, and a report of a shoulder dystocia complicating the delivery. The information most commonly absent in the notes was the use of epidural analgesia (6% of notes), identification of anterior shoulder (18%), and whether or not cord gases were sent (18%). Although 91% (n = 30) recorded the Apgar scores, 2 residents recorded the scores incorrectly.
Because a shoulder dystocia may result in serious and permanent injury to the infant and also because this is usually an unpredictable event, it is imperative that residents and staff are not only trained to resolve the problem quickly, but also taught how to document all appropriate facts regarding the case. Although thorough and accurate documentation does not mean that, if litigation occurs, a judgment will not be made against the physician, it can prevent a finding or appearance of negligence. Indeed, it has been suggested that if the record is silent, there is no defense.5 Regarding documentation, one study of 294 obstetric malpractice claims noted that problems with documentation alone were responsible for 5% of indefensible cases.6
After simulation training with a standardized shoulder dystocia scenario, residents’ delivery notes were lacking many key components. Of 15 key variables that we assessed, the median number included by the residents was only 8, and 76% of residents recorded fewer than 10 of 15 key components of the note. Although it is understandable that a minority of residents did not note that umbilical cord gases were sent because they may not have done this during their simulation, it is of concern that so few residents (18%) noted which shoulder was anterior during the shoulder dystocia delivery and that fewer than half (45%, 15/33) gave an estimate of how long the head-to-body interval lasted. Both of these are key components in evaluating the child for birth injuries and necessary documentation in the event that a lawsuit is brought against the physician.
Just as important as demonstrating that the complication was handled appropriately, however, is the fact that accurate documentation is essential to providing better patient care. If the estimated blood loss is not recorded, the obstetrician and nurses may not be as vigilant in assessing the patient for evidence of hypovolemia from hemorrhage. And if the obstetrician cannot or does not record which shoulder was anterior or exactly how long the infant was on the perineum, it may be more difficult for a pediatrician reviewing the notes to determine what to expect in the immediate neonatal period.
Requiring the residents to write a delivery note as part of our birthing simulation curriculum identified deficiencies in medical documentation. The act of debriefing the residents following their simulation exercise and reviewing with them their delivery notes constitutes a valuable teaching moment. Although this current report does not address our ability to improve the trainee's documentation skills, we speculate that this timely and direct feedback may lead to increased awareness of the importance of the delivery note and subsequent improvement in documentation. In an editorial in the Obstetrics & Gynecology, Dr. Queenan7 asserted that documentation is a key factor in avoiding a lawsuit. Residents in training must be aware of clinical events, such as shoulder dystocia, that may precipitate malpractice claims. They must develop strategies, including proper documentation procedures, to minimize the risk of such claims. Educators need to evaluate their residents’ understanding of risk management and develop curriculum to teach risk reduction. The use of the delivery note and feedback regarding the note provide a simple and potentially important addition to simulation teaching models that allows instructors to identify deficiencies in documentation. Additional research into techniques to improve documentation with this tool should be pursued.
1. Strunk AL, Esser L, Frazier S, Guenther M. Overview of the 1999 survey of professional liability. ACOG Clin Rev 2000;5:1, 15–6.
2. Education Committee of the Council on Resident Education in Obstetrics and Gynecology. Educational objectives, core curriculum for residents in obstetrics and gynecology. 7th ed. Washington, DC: The American College of Obstetricians and Gynecologists; 2002.
3. Deering S, Poggi S, Macedonia C, Gherman R, Satin AJ. Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol 2004;103:1224–8.
4. Acker DB. A shoulder dystocia intervention form. Obstet Gynecol 1991;78:150–1.
5. Richards BC, Thomasson G. Closed liability claims analysis and the medical record. Obstet Gynecol 1992;80:313–6.
6. Ward CJ. Analysis of 500 obstetric and gynecologic malpractice claims: causes and prevention. Am J Obstet Gynecol 1991;165:298–306.
7. Queenan JT. Professional liability: storm warning. Obstet Gynecol 2001;98:194–7.