Expert Commentary
Is it time to revive rotational forceps?
Contemporary data suggest that it is.
Maternal and neonatal outcomes
Postpartum hemorrhage was more common in the suboptimal placement group (24.6% vs 14.4%; OR, 1.94; 95% CI, 1.19–3.17; P = .008), as was prolonged hospitalization (26.8% vs 14.7%; OR, 2.13; 95% CI, 1.31–3.44; P = .02).
In addition, the incidence of neonatal trauma was higher in the group with suboptimal placement (15.9% vs 3.9%; OR, 4.64; 95% CI, 2.25–9.58; P<.0001) and included such effects as Erb’s palsy, fracture, retinal hemorrhage, cephalhematoma, and cerebral hemorrhage.
After adjustment for potential confounding factors, including induction of labor, seniority of the obstetrician, fetal malposition, caput above +1, midcavity station, regional analgesia, and the instrument used, the association remained significant between suboptimal placement and prolonged hospitalization (adjusted OR, 2.28; 95% CI, 1.30–4.02) and neonatal trauma (adjusted OR, 4.25; 95% CI, 1.85–9.72).
Dwindling statistics for operative vaginal delivery
In an editorial accompanying the study by Ramphul and colleagues, Dwight J. Rouse, MD,points to the waning of instrumental vaginal delivery in many parts of the world, most notably the United States, where, in 2012, only 2.8% of live births involved use of a vacuum device and only 0.6% involved the forceps.5
“When the rate of cesarean delivery is 10 times the combined rate of vaginal vacuum and forceps delivery (as it is in the USA), it is fair to argue that operative vaginal delivery is underutilized,” Dr. Rouse writes. “So kudos to Ramphul et al for providing insight into how we might continue to perform operative vaginal delivery safely.”
What this EVIDENCE means for practice
The study by Ramphul and colleagues very clearly confirms that correct placement of the vacuum device or forceps is key to safety.
Should we continue forceps education using the apprenticeship model of training?
Kyser KL, Lu X, Santillan D, et al. Forceps delivery volumes in teaching and nonteaching hospitals: Are volumes sufficient for physicians to acquire and maintain competence? Acad Med. 2014;89(1):71–76.
Ericsson KA. Necessity is the mother of invention: video recording firsthand perspectives of critical medical procedures to make simulated training more effective. Acad Med. 2014;89(1):17–20.
Kyser and colleagues have provided the best current snapshot of the opportunity for teaching instrumental vaginal delivery in the United States. They conducted a retrospective cohort study using new state inpatient data from 9 states in diverse geographic locations to capture experience at large and small teaching hospitals, as well as nonteaching institutions. They demonstrated that the opportunity for hands-on experience with these difficult and technically demanding deliveries is extremely limited and probably insufficient for all practicing physicians to maintain their skills if we continue to rely on traditional ways of teaching.
Details of the study
Using State Inpatient Data from 9 states, Kyser and colleagues identified all women hospitalized for childbirth in 2008. Of 1,344,305 deliveries in 835 hospitals, the final cohort included 624,000 operative deliveries—424,224 cesarean deliveries, 174,036 vacuum extractions, 6,158 forceps deliveries, and 19,582 deliveries that required more than 1 method. Of the 835 hospitals in this study, 68 were major teaching hospitals, 130 were minor teaching facilities, and 637 were nonteaching institutions.
The mean annual volumes for cesarean delivery for major teaching, minor teaching, and nonteaching hospitals were 969.8, 757.8, and 406.9, respectively (P<.0001).
The mean annual volumes for vacuum delivery were 301.0, 304.2, and 190.4, respectively (P<.0001).
The mean annual volumes for forceps delivery were 25.2, 15.3, and 8.9, respectively (P<.0001).
Three hundred twenty hospitals (38.3% of all hospitals) failed to perform a single forceps delivery in 2008, including 11 major teaching hospitals (16.2% of major teaching hospitals), 30 minor teaching hospitals (23.1% of minor teaching hospitals), and 279 nonteaching hospitals (43.8% of nonteaching hospitals) (P<.0001).
We need to rethink the apprenticeship model
In a commentary accompanying the study by Kyser and colleagues, K. Anders Ericsson, PhD, revisits the “see one, do one, teach one” model that has long characterized medical education. “Both the limitations on learning opportunities available in the clinics and the restrictions on resident work hours have created a real problem for the traditional apprenticeship model for training doctors,” he writes.
Ericsson notes that other specialists, such as concert musicians, chess players, and professional athletes do not learn using an apprenticeship model. For example, chess players do not play game after game of chess to become expert. And when a game is concluded, usually after several hours have passed, they are unlikely to be aware of the specific moves that lost or won them the game (unless an observer points them out). That is why, when training, chess players focus on particular aspects of the game (often identified by a mentor) as being crucial to improve their overall performance.
