Dystocie des épaules : évaluation de la qualité de la retranscription dans les dossiers médicaux

Conclusion Afin d’améliorer la prise en charge des dystocies des épaules et la retranscription des données dans les dossiers, des séances de simulation ainsi que la création d’une fiche standardisée seraient nécessaires. Objective Shoulder dystocia is a rare obstetrical event and potentially serious. Apart from possible psychological implications, it may be responsible for maternal (haemorrhage and perineal tear) and neonatal complications (brachial plexus) leading to complaints and even lawsuits. The transcription of this event in medical files is essential as it is a reflection of the work in an emergency. It allows the obstetrician to defend him in case of trial. Our objective was to assess the quality of the transcription of shoulder dystocia situations in medical files. Method Retrospective chart study conducted in a university hospital with maternity type III. The primary objective was the rate of comprehensive records (name maneuvers and order of maneuvers of the anterior shoulder hand, time between the expulsion of the head and body, Apgar score). Results Between 2007 and 2015, 54 cases of shoulder dystocia requiring a second line maneuver after vaginal delivery (Wood and/or Jacquemier) were included. In all, 98.2% of the files were incomplete. The maneuvers and their order were noted in 100% of cases. However, the operation was not correctly described in 16.7% of cases. The anterior shoulder was noted in 16.7% of cases. The time between the expulsi...
Source: Gynecologie Obstetrique and Fertilite - Category: OBGYN Source Type: research