Date______________ Patient ______________________________ Date of birth __________ MR #_____________ Physician or certified nurse–midwife______________________________ Gravidity/Parity______________________ Timing: Onset of active labor___________ Start of second stage_______ Delivery of head___________ Time shoulder dystocia recognized and help called__________ Delivery of posterior shoulder___________ Delivery of infant_________ Antepartum documentation: ❏ Assessment of pelvis ❏ History of prior cesarean delivery: Indication for cesarean delivery: _________________________________ ❏ History of prior shoulder dystocia ❏ History of gestational diabetes ❏ Largest prior newborn birth weight__________ ❏ Estimated fetal weight_________ ❏ Cesarean delivery offered if estimated fetal weight greater than 4,500 g (if the patient has diabetes mellitus) or greater than 5,000 g (if patient does not have diabetes mellitus) Intrapartum documentation: ❏ Mode of delivery of vertex: ❏ Spontaneous ❏ Operative delivery: Indication:__________________________________________ ❏ Vacuum ❏ Forceps ❏ Anterior shoulder: ❏ Right ❏ Left ❏ Traction on vertex: ❏ None ❏ Standard ❏ No fundal pressure applied ❏ Maneuvers utilized (1): ❏ Hip flexion (McRoberts maneuver) ❏ Suprapubic pressure (stand on the side of the occiput) ❏ Delivery of posterior arm ❏ All fours (Gaskin maneuver) ❏ Posterior scapula (Woods maneuver) ❏ Anterior scapula (Rubin maneuver) ❏ Abdominal delivery ❏ Zavanelli maneuver ❏ Episiotomy: ❏ None ❏ Median ❏ Mediolateral ❏ Proctoepisiotomy ❏ Extension of episiotomy: ❏ None ❏ Third degree ❏ Fourth degree ❏ Laceration: ❏ Third degree ❏ Fourth degree ❏ Cord blood gases sent to the laboratory: ❏ Yes: Results:______________________________ ❏ No ✓ Patient Safety Checklist DOCUMENTING SHOULDER DYSTOCIA Number 6 • August 2012 (continued) (continued) ❏ Status of neonate prior to leaving delivery room or operating room: Apgar scores____________________ Evidence of injury________________ Birth weight (if available)__________ ❏ Staff present_____________________________________________________________________ ❏ Family members present____________________________________________________________ ❏ Patient and family counseled ❏ Debriefing with appropriate personnel Postpartum/neonatal documentation: ❏ Delivery discussed with family ❏ Perineal assessment if third or fourth degree laceration ❏ Monitored for postpartum hemorrhage: ❏ Yes: Results:_____________________________ ❏ No ❏ Communication with pediatrics department if there is evidence of injury or asphyxia ❏ Coordination of follow-up care for mother and baby ❏ Monitored for postpartum depression: ❏ Yes: Results:_____________________________ ❏ No Procedural Elements for Shoulder Dystocia The following steps should be taken when managing shoulder dystocia: 1. Call for help from pediatrics, anesthesia, and neonatal intensive care unit staff, and assign a timekeeper 2. Initiate maneuver (eg, McRoberts maneuver) 3. Re-evaluate course of actions, including using other maneuvers or repeating maneuvers if unsuccessful 4. Consider abdominal delivery 5. Document event—move to documentation checklist Reference 1. Shoulder dystocia. ACOG Practice Bulletin No. 40. American College of Obstetricians and Gynecologists. Obstet Gynecol 2002;100:1045–50. [PubMed] [Obstetrics & Gynecology] ^ Standardization of health care processes and reduced variation has been shown to improve outcomes and quality of care. The American College of Obstetricians and Gynecologists has developed a series of Patient Safety Checklists to help facilitate the standardization process. This checklist reflects emerging clinical, scientific and patient safety advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Although the components of a particular checklist may be adapted to local resources, standardization of checklists within an institution is strongly encouraged. How to Use This Checklist The Patient Safety Checklist on Documenting Shoulder Dystocia should be used to guide the documentation process if a patient has experienced shoulder dystocia. Copyright August 2012 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photocopies should be directed to: Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400. Documenting shoulder dystocia. Patient Safety Checklist No. 6. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:430–1.

American College of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188 | Mailing Address: PO Box 70620, Washington, DC 20024-9998