Shoulder Dystocia Event Note

Date of Delivery: [Date]

Delivery Location: [Unit/room]

Gestational Age: [Weeks+days]

Mode of Delivery: [spontaneous vaginal / operative vaginal (forceps) / operative vaginal (vacuum) / VBAC / other]

Delivering Clinician: [Name, credentials, and role]

Note Author: [Name, credentials, and role] (Include only if different from delivering clinician)

Event Summary

[Narrative summary of shoulder dystocia event] (Write 3–6 sentences in factual, time-anchored language. Include: diagnosis with exact time recognized, call for help and initial response, maneuver sequence in order performed identifying which achieved delivery, immediate newborn status, and immediate maternal status. Avoid speculation or commentary.)

Timeline

• Time fetal head delivered: [HH:MM or HH:MM:SS] (Use absolute time; if unknown, state "unknown" with brief explanation; if approximate, label as such with stated basis)
• Time shoulder dystocia recognized: [HH:MM or HH:MM:SS / same as head delivery / unknown]
• Time help called: [HH:MM or HH:MM:SS / unknown]
• Time of complete delivery: [HH:MM or HH:MM:SS / unknown]
• Head-to-body interval: [Interval in seconds] (Calculate from head delivery to body delivery; if approximate, label as such)
• Time source(s): [bedside clock / EHR system time / nursing log / neonatal record / anesthesia record / other] (If multiple sources with discrepancies, acknowledge rather than harmonize)

Situation at Diagnosis

• Fetal vertex position: [OA / OP / ROT / LOT / ROP / LOP / ROA / LOA / unknown]
• Anterior shoulder: [Left / Right / Unknown] (Always include; if unknown, state explicitly)
• Maternal position at diagnosis: [lithotomy / dorsal lithotomy / semi-recumbent / lateral / hands-and-knees / other]
• Anesthesia status: [none / epidural / spinal / combined spinal-epidural / local / pudendal / other]
• Operative vaginal delivery preceding dystocia: [No / Yes – instrument type and indication]
• Episiotomy: [not performed / performed – timing relative to maneuvers and type]

Personnel Present

(List all personnel present during the event with roles. Include arrival times for key responders when available.)

• Delivering clinician(s): [Name(s) and role(s)]
• Nursing staff: [Name(s) and role(s)]
• Anesthesia: [Already present / Called at HH:MM, arrived at HH:MM / Not called]
• Pediatrics/Neonatology: [Already present / Called at HH:MM, arrived at HH:MM / Not called]
• Other responders: [Name(s), role(s), and arrival time(s)]

Maneuvers Performed

(Document each maneuver in exact chronological order performed—do not reorder into textbook sequence. Use neutral, descriptive language. For traction, describe direction and qualifier only if supportable; otherwise state "traction force not quantified." If dystocia resolved with initial maneuver alone, state explicitly.)

• [Maneuver 1 name]: [Time initiated] – [Performed by name and role] – [Brief description of technique] – [Duration or number of attempts] – [Result: released / partial release / no release]
• [Maneuver 2 name]: [Time initiated] – [Performed by name and role] – [Brief description of technique] – [Duration or number of attempts] – [Result: released / partial release / no release]
• (Add additional maneuvers as needed, maintaining chronological order)

(For posterior arm delivery, specify which arm. For rotational maneuvers, specify Rubin, Woods screw, or reverse Woods. For suprapubic pressure, specify direction if tracked.)

Maternal Outcome

• Estimated blood loss: [EBL in mL] [PPH criteria met / PPH criteria not met]
• Perineal laceration: [none / 1st degree / 2nd degree / 3rd degree (3a/3b/3c) / 4th degree] – [Repair status]
• Vaginal/cervical lacerations: [none / description and repair status]
• Other complications: [none / symphyseal symptoms / nerve injury symptoms / other]
• Perineal exam status: [completed / exam pending]

Newborn Status

• Sex: [Male / Female]
• Birth weight: [Weight in grams]
• Apgar scores: 1 min: [Score], 5 min: [Score] (If 5-minute score < 7, include 10-, 15-, and 20-minute scores)
• Cord blood gases: [Arterial obtained – pH, base excess / Venous obtained – pH, base excess / Pending / Not obtained – reason]
• Resuscitation: [Care assumed by team/provider] – [Interventions: stimulation / suctioning / PPV / CPAP / intubation / chest compressions / medications / none required]
• Disposition: [rooming-in / special care nursery / NICU admission]
• Early injury assessment: [Symmetry of arm movement, Moro reflex, grasp, presence of crepitus/deformity/bruising] (Document "no abnormalities on initial exam" if none; if performed by pediatrics/neonatology, attribute findings)

Communication and Follow-up

• Parent/birthing person informed: [Yes – time and summary of explanation provided / Deferred – reason]
• Opportunity for questions: [Yes / No – reason]
• Known/suspected injuries discussed: [None / Injuries discussed and planned evaluations]
• Team debrief: [Performed – time and participants / Not performed – reason]
• Follow-up plans: [Maternal and newborn evaluation needs, referrals, pending results]

(General documentation guidance: Use factual, time-based language throughout. Attribute information from other sources. Document "unknown" with explanation rather than omitting required fields. Avoid speculation regarding injury causation. Acknowledge discrepancies between sources explicitly.)