Evaluation of residents' delivery notes after a simulated shoulder dystocia.

OBJECTIVE: To describe and analyze delivery notes after a shoulder dystocia drill with a birthing simulator

METHODS: A total of 33 residents from 2 university training programs underwent testing on a standardized shoulder dystocia scenario with an obstetric birthing simulator. After the completion of the delivery, each resident was informed of the infant's Apgar scores and birth weight and told that the infant was moving all extremities. The resident was then given a blank progress note and asked to write a delivery note. The notes were evaluated for 15 key components.

RESULTS: Seventy-six percent (n = 25) of residents recorded less than 10 of 15 key components of a delivery note after a shoulder dystocia. The majority of residents (91%, 30/33) included the correct order of the maneuvers used during the delivery, but most did not note which shoulder was anterior (18%, 6/33) or how long the head-to-body interval was during delivery (45%, 15/33).

CONCLUSION: Residents' delivery notes after a shoulder dystocia simulation often lacked critical elements. Training in documentation is needed in residency training. The addition of the delivery note and feedback regarding the note represents a simple innovation in this teaching scenario that may help identify deficiencies in documentation.

LEVEL OF EVIDENCE: III