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Chart documentation of informed consent for operative vaginal delivery: is it adequate?
Catherine Matthews Nichols1, Laura C Pendlebury, Jamie Jennell
1Department of Obstetrics and Gynecology, School of Medicine, Medical College of Virginia/Virginia Commonwealth University Medical Center, Richmond, VA, USA. cmnichol@hsc.vcu.edu
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.
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