Sample Delivery Note: Shoulder Dystocia | Obstetric Safety Initiative | Health Care Professionals | Dartmouth-Hitchcock
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Sample Delivery Note: Shoulder Dystocia

Patient Name: _________________
MRN: _________________
Primary author of this note: _________________
Date: _________________

This is a _________________ vaginal delivery complicated by shoulder dystocia. Shoulder dystocia was diagnosed based on _________________.

The fetal head was in a _________________ rotation.

The following individuals were present at the delivery _________________.

Pediatricians were _________________ called to the delivery at the time of diagnosis of the shoulder dystocia.

The following maneuvers listed in order were used in an attempt to resolve the shoulder dystocia. (List in correct order of use, and add additional descriptions if appropriate. Erase the ones you didn't use)

(_________________) McRoberts
(_________________) Delivery of Posterior Arm
(_________________) Woods Screw
(_________________) Knee Chest
(_________________) Zavanelli

_________________ was not attempted due to _________________.

An episiotomy was _________________ performed. There were _________________ lacerations.

The time elapsed from delivery of the head to delivery of the body was _________________.

The neonate appeared _________________ at delivery (describe meconium, nuchal cord, any other findings)

Apgar scores were _________________/_________________/_________________.

The placenta appeared _________________ and was _________________ sent to pathology.

The mother appeared _________________ immediately postpartum.

I _________________ discuss the shoulder dystocia with the patient and her family and its potential implications.

The mother and family expressed concern regarding _________________.

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