Date:
Patient:
Gravida: [Gravidity] | Parity: [Parity]
Attending Physician:
Anesthesia: (e.g., epidural, general)
Delivery Information:
Vaginal delivery: Yes / No (If Cesarean section, document separately)
Estimated fetal weight (EFW): [Weight] grams
Bishop score (if documented): [Score]
History of Present Illness:
Briefly describe the course of labor, including:
Presentation (cephalic, breech)
Duration of active labor
Augmentation or induction of labor (if applicable)
Maternal pushing efforts
Shoulder Dystocia Maneuvers:
Document all maneuvers attempted for delivery of the posterior shoulder, including:
McRoberts maneuver
Suprapubic pressure (fundal pressure)
Maurice maneuver (internal)
Woods’ corkscrew maneuver (internal)
Zavanelli maneuver (internal)
Episiotomy extension (if performed)
Delivery Outcome:
Mode of delivery of the posterior shoulder: (e.g., spontaneous, manual)
Fetal Apgar scores:
1 minute: [Score]
5 minutes: [Score]
Birth injuries (if any): (e.g., clavicle fracture, brachial plexus injury)
Maternal Complications (if any):
(e.g., postpartum hemorrhage, lacerations)
Assessment:
Briefly summarize the course of delivery and the maneuvers used to manage the shoulder dystocia.
Discuss the potential causes of shoulder dystocia based on the delivery information (e.g., macrosomia, maternal diabetes).
Mention the infant’s Apgar scores and any birth injuries sustained.
Plan:
Fetal monitoring: Monitor the infant for signs of complications related to birth injuries (e.g., neurological assessment, vascular assessment).
Management of birth injuries: Discuss the plan for managing any identified birth injuries, including referrals to specialists (e.g., orthopedics, physical therapy).
Maternal care: Address any maternal complications and plan for postpartum care.
Documentation: Document the shoulder dystocia event in the labor and delivery record and the infant’s medical record.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of shoulder dystocia