The documentation and reporting of shoulder dystocia in a district hospital

Abstract

Background In previous studies it has been suggested that proformas may improve the noting of shoulder dystocia (SD) management and outcomes. Objectives To determine the method and accuracy of recording of the number of SD cases in a District Hospital (DH) in 2007 and 2008. To measure the completeness of SD reporting forms. To report on how many cases of SD are reviewed by the risk management team. To make improvements to the current system of documenting and reporting SD. Method A purposeful and representative sample of 29 patients was triangulated from the trust database, birth register and clinical incident report forms. A proforma was used to check the documentation of SD management in the notes for the essential components. Results 81.8% of the true cases of SD had reporting forms present in their notes. Average completeness of the reporting forms was 82%. Where a proforma had been completed: paediatricians were noted to have been called in 50% of cases, obstetricians in 72% of cases. Clinical incident reports were made in 59.1%. Clinical incident reviews were carried out in all reported events. Conclusion The 100% standards of recording and reporting SD are not being met in the DH; however, the 100% standard for the reviewing of reported cases is being upheld. The reporting form has been revised to tackle the weaknesses highlighted in this audit and its effectiveness is due for re-audit.