Efficacy of Checklists on Proper Documentation of Operative Vaginal Deliveries [132]

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INTRODUCTION: Operative vaginal delivery is a common obstetric procedure that requires appropriate documentation to maintain patient safety and quality of care. Although checklists have been shown to improve both quality and safety, the role of checklists in operative vaginal delivery has not been well studied. We aimed to determine whether the implementation of a checklist improved the documentation around operative vaginal delivery. METHODS: This was a retrospective cohort study of documentation of all consecutive operative vaginal deliveries performed at an academic tertiary care institution both before and after the implementation of a checklist for operative deliveries. A total of 15 documentation points were reviewed for vacuum deliveries with 17 points reviewed for forceps deliveries. These included preprocedure, intraprocedure, and postprocedure criteria. Wilcoxon rank-sum test, χ2, and Fisher's exact test were used to compare documentation between the two groups. RESULTS: A total of 186 charts were reviewed with 82 (44%) before checklist implementation and 104 (56%) after. The use of the checklist improved documentation with 79% of criteria documented after the implementation and 57% before (P<.001). The use of the checklist improved documentation of estimated fetal weight, whether the bladder was emptied, number of popoffs for a vacuum delivery, maternal estimated blood loss, and newborn evaluation by the pediatric team. CONCLUSION: Implementation of a documentation checklist for operative vaginal delivery significantly improves clinician documentation. This documentation may have improved teaching at an academic institution. The documentation for operative vaginal delivery is critical for patient safety and quality of care as well as to prevent litigation.

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