Original Article

Chart Documentation of Informed Consent for Operative Vaginal Delivery: Is It Adequate?

Authors: Catherine Matthews Nichols, MD, Laura C. Pendlebury, MD, Jamie Jennell

Abstract

Objectives: To determine the documentation frequency of informed consent for women undergoing a trial of nonemergent instrumental delivery.


Study Design: A retrospective chart review of instrumented vaginal deliveries from 1992 to 2005 was performed. Cases were identified from a Labor and Delivery database and hospital records were reviewed for documentation of associated risks, general consent for the procedure, indication, and option of cesarean delivery (CD).


Results: Three hundred forty six charts were reviewed: 246 were excluded for an emergency delivery (19%), misclassification (25%), or lost notes (27%). In the remaining 100 cases, 61% had a general consent for instrumented vaginal delivery. Documentation of any maternal or neonatal risks was found in 3% and 0%, respectively. The option of a cesarean delivery was documented in 22% of the cases. When comparing 5-year time intervals before and after 2000, there was no increased frequency in documentation of maternal or neonatal risks.


Conclusions: Documentation of informed consent for instrumented vaginal delivery is inconsistent and should be improved.


Key Points


* More than one-third of women undergoing an elective trial of instrumental vaginal delivery did not have chart documentation of general consent for the procedure.


* Any maternal and/or neonatal risk of instrumental vaginal delivery was documented in 3% and 0% of charts reviewed, respectively.


* Documentation of the known maternal and/or neonatal risks of instrumental vaginal delivery did not improve over time.


* Documentation of informed consent for instrumental vaginal delivery is inconsistent and should be improved

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