Documentation of instrumental vaginal deliveries

Abstract

Background:

Instrumental vaginal deliveries (IVDs) account for approximately 11% of births in Australia. Complications resulting from IVD can occasionally be the subject of litigation. The Royal College of Obstetricians and Gynaecologists suggests a standardised pro forma in their guidelines as an aid to accurate and complete IVD documentation. Many units, including ours, use less structured reporting, which is probably also less adequate.

Aim:

To assess whether the introduction of a dedicated IVD form improves the quality of IVD documentation.

Method:

Analysis of the quality of IVD documentation before and after the implementation of a new dedicated IVD form. A survey to evaluate clinicians’ opinion on the new standardised form.

Results:

Significant improvement was found in documentation of key information including the documentation of caput (p < 0.05), type of instrument, number of ventouse cup detachments, moulding of specific sutures, abdominal palpation (number of fifths of foetal head palpable), liquor colour and total time of instrument application (p < 0.001). A majority of clinicians believed the form to be beneficial in terms of completeness and that it reduced the amount of time required for documentation.

Conclusions:

IVD documentation is enhanced by the use of a dedicated form. Clinical judgement may also be enhanced by the discipline involved in the formal assessment required by the form.