The role of rotational forceps



I read with interest the article by Tempest et al.[1] on a re-evaluation of the role of rotational forceps. Their elegant study clearly shows that assisted vaginal birth by Kielland forceps is an effective and safe means to achieving a vaginal delivery when malposition complicates the second stage of labour, if undertaken by experienced hands.

Aye, there's the rub. Experienced hands. Experienced hands are an increasingly rare commodity. I reviewed the maternity theatre register of a district general hospital where I once worked in 1993: middle-grade cover was provided by two doctors in training and one non-career post. In the space of 1 year, the two doctors in training each performed approximately 160 caesarean sections. I reviewed the maternity theatre register of the same hospital in 2011. The delivery numbers and caesarean section rate were broadly unchanged. But the staffing level was vastly different. In order to comply with the European Working Time Directive (EWTD), middle-grade cover was provided by seven doctors in training. In addition, some resident cover was also provided by consultants. In 2011, on average, trainees were performing 50 caesarean sections per annum. This demonstrates the massive reduction in practical experience that doctors in training gain, which has come with no corresponding increase in the time spent in training.

Because of this reduction in practical experience and a lack of experienced hands, I believe it is unlikely that we will witness a return to the increased use of rotational forceps – at least in the foreseeable future. This study was run between 2006 and 2010. The full impact of the EWTD only came into force in 2009. There is well-documented evidence on the negative effect of the EWTD on the practical skills gained by doctors in training as well as the intensity with which practical skills are learned.[2] And as a result, I feel trainees are less likely to opt for using an instrument that they may feel inadequately trained to use. And because of the perceived risks (real or otherwise) associated with the use of rotational forceps, local guidelines may well be designed to discourage their use.[3]

It is unfortunate that a safe and effective alternative to caesarean section for malposition complicating the second stage of labour is unlikely to be widely adopted because of a lack of experienced hands to teach the technique. Caesarean section in the second stage of labour is fraught with difficulties and dangers. It may be that the driving force for the re-introduction of Kielland forceps will be when we fully recognise the harm caused by caesarean sections performed at full cervical dilatation for malposition. Particularly so if these caesarean sections are undertaken by obstetricians who have had significantly less experience than trainees once had.