Chart documentation of informed consent for operative vaginal delivery: is it adequate?

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.

journal_name

South Med J

journal_title

Southern medical journal

authors

Nichols CM,Pendlebury LC,Jennell J

doi

10.1097/01.smj.0000243076.86803.09

subject

Has Abstract

pub_date

2006-12-01 00:00:00

pages

1337-9

issue

12

eissn

0038-4348

issn

1541-8243

journal_volume

99

pub_type

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