9. Document, document
Under ideal circumstances, the obstetrician initiates a discussion with the patient during prenatal care and mentions the possibility of vacuum extraction or forceps delivery. This discussion is documented in the prenatal chart. The note includes a statement discussing the relative risks and benefits of the alternative delivery modes, the patient’s expressed desire for a vaginal delivery, including operative vaginal delivery, and why, in the physician’s best judgment, an operative vaginal delivery is a reasonable option.
Document the events of labor and delivery
Clear, concise progress notes from nursing and obstetric care providers are extremely important. All pertinent maternal and fetal information should be addressed at each examination of the patient, and some comment on the rate of progress, threshold limits, management plan, and preparations should be included.
In my opinion, each progress note should describe maternal vital signs, adequacy of contractions, use of labor augmentation and the dose, fetal tolerance of contractions, reassuring nature of the monitoring, cervical dilation, fetal head position (if discernible), station, and any molding and caput. If maternal or fetal monitoring is inadequate with external devices, the notes should include details of the plan to improve the situation.
Include a preoperative note
I strongly recommend a preoperative note if there is time. It should clearly document the pertinent obstetric and prenatal care the patient has received, the progress of labor, the indication for operative vaginal delivery, estimated fetal weight, adequacy of the maternal pelvis for an infant of the anticipated weight, fetal head position, degree of molding, complete dilation of the cervix, station of the fetal head, and some assessment of flexion of the neck, if possible.
Once the decision to proceed has been made, I would add a statement indicating that the chances of success are high and, in your considered opinion, operative vaginal delivery is a safe and indicated option.
Write a detailed postoperative note
I suggest a dictated postoperative note for every operative vaginal delivery, successful or not. The elements included in the preoperative note should be reiterated and details of the delivery explained. The position and station of the fetal head at the time the instrument was applied (especially if this contrasts with what was stated in the preoperative note), the degree of caput and molding, the number and duration of traction efforts, progress of the fetal head with each traction effort, duration of the procedure, personnel present, and the preparations made for the delivery should all be documented. Physicians and nurses should agree on what constitutes a traction effort, to avoid conflicts in the various sets of notes.
Document postdelivery vaginal and rectal examinations, which should alert you to the presence of any retained sponges, vaginal hematomas or sulcus tears, or a previously unidentified rectovaginal fistula.
10. Handle bad outcomes with compassion
Do not avoid contact with the family in the event of a bad outcome. Rather, confront the outcome as honestly and compassionately as possible. If you correctly assessed and informed the patient and proceeded to operative vaginal delivery with her full understanding of the indication, she will have accepted a small risk of an untoward outcome. In general, if she perceives your behavior to have been professional and caring, she is much less likely to seek retribution.
The author reports no financial relationships relevant to this article.