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Table 4: Shoulder dystocia documentation

1) Personal details
Name :
MRN : Date :

2) Delivery Details (Please tick the appropriate box)

2.1) Mode of delivery:
a) Spontaneous b) Ventouse c) Forceps

2.2) Time of delivery of fetal head:

2.3) Professional in attendance during delivery of fetal head:
Name Designation
1)
2)

2.4) Time called for help:

2.5) Additional professionals during delivery of fetal shoulders:
Name Designation Time of arrival
1)
2)

3) Manoeuvres used to assist delivery

Manoeuvre Name Designation Time Sequence
McRoberts
Suprapubic pressure
Episiotomy
Delivery of posterior arm
Woods Screw/ Reverse
Gaskin

3.1) Other advanced manoeuvres

Manoeuvre Name Designation Time Sequence
1.
2.

3.2) Time of delivery of fetal shoulder:

3.3) Head to body delivery interval:
3.4) Fetal position during dystocia (Please tick the appropriate box)
Head facing maternal right Head facing maternal left
(Right fetal shoulder anterior) (Left fetal shoulder anterior)

4) Details of fetus
4.1) Birth weight: 4.2) APGAR score: 1st min - 5th min -
4.3) Cord blood gases: Arterial pH: Arterial BE:
Venous pH: Venous BE:

5) Paediatrician in attendance 6) Debrief to parents

Name Designation Time Name Designation
1) 1)
2) 2)

Form completed by:

Name : Designation :
Date : Time : Signature :

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