We thank the reader for commenting on this important issue.
We agree with the reader that second-stage malposition is a complex acute clinical situation needing an experienced clinician to provide advanced obstetric care. Indeed, we argue that rotational vaginal birth of all types and full-dilatation caesarean sections are all advanced surgical procedures, not suitable to be provided by inexperienced clinicians.
The recent changes in delivering obstetric services in the UK has provided an opportunity with consultant-based intrapartum care provision to improve the training, regulation, and performance of rotational deliveries, to achieve a safe and best outcome for the mother and the baby. As a result, although the number of procedures performed by doctors in training may have been reduced over the last few years, the number of procedures that are performed under direct supervision from a senior trainer may possibly have increased. This is highlighted by the reader's review of the situation in a district general hospital where consultants were now available as residents at night. However, the practice of rotational deliveries we reported does not seem to be unusual in the UK, with a number of other large units adopting similar practices (pers. comm.: Royal Infirmary of Edinburgh; St Mary's Hospital, Manchester; and Birmingham Women's Hospital). The increased direct presence of senior consultants, with all UK trainees in the obstetrics training programme rotating to busy tertiary centres and less busy district general hospitals, will allow most future obstetricians to gain the necessary skills in advanced rotational deliveries.
Noticeably, other methods with no explicit description on how to perform them, or data on their safety or efficacy, such as manual rotation, are routinely being employed and championed by some obstetricians: they even regard manual rotation to be a safer alternative to the classical rotational methods, even in inexperienced hands.
We argue that advanced Obstetrics training should include opportunities for the trainees to achieve training in all methods of delivery, including Kielland forceps.[1, 2] As the Royal College of Obstetricians and Gynaecologists (RCOG) recommend increasing the presence of consultants in the labour ward and reducing caesarean delivery rates in the UK, high-quality, regulated training and the performance of assisted rotational vaginal deliveries should be a goal in planning future obstetrics services.[1-4] Guidelines should be in place for performing, training, and documenting these deliveries that require the highest level of skills in acute obstetrics practice.