We read with interest the Editor's Choice comments on The choice of instrument for assisted vaginal delivery, and indeed the index paper by Tempest et al.[1] to which the comments relate, and further correspondence relating to it.[2]

We completely agree that appropriate choice of instrument and expertise in its use can reduce second-stage caesarean section with its associated complications. We also agree that the total time available for training before becoming an independent specialist has reduced significantly. There have also been reforms to junior doctors’ training as a result of societal, political and academic pressures. A recent national trainees’ survey highlighted that training in the management of operative birth in the second stage of labour, especially when there is malposition of the fetal head, is a priority.

This trend to de-skilling in operative vaginal birth is not limited to the UK; some developing countries have very low operative vaginal birth rates, and consequently high caesarean section rates. This might have a significant adverse impact on the maternal mortality ratio in many developing countries; the caesarean-section-specific maternal mortality ratio in many parts of the developing world is now over 500. Moreover, this figure does not take into account the increased risk of morbidity and mortality for women with a uterine scar in subsequent pregnancies.[3]

We believe that simulation-based education has the potential to improve training in both operative vaginal birth and second-stage caesarean section for the benefit of women and their babies. With the Royal College of Obstetricians and Gynaecologists (RCOG) we have recently developed the ROBuST (RCOG Operative Birth Simulation Training) Course to improve training and practice in operative birth. The course includes hands-on practice of nonrotational and rotational operative vaginal birth using both forceps and vacuum, as well as techniques for dis-impaction of the fetal head at second-stage caesarean section. Communication, debriefing and documentation are also practised; an extensive programme of research has informed the teaching. The accompanying manual provides comprehensive information for participants, with individual chapters commissioned from nationally and internationally recognised experts. A Train the Trainers package is also being developed, to enable the ROBuST Course to be delivered regionally (similar to RCOG Basic Practical Skills) and to provide quality assurance.

Simulation training in obstetrics can facilitate learning in practical and communication skills in a safe environment, without any risk of patient harm. We strongly believe that simulation has a significant role in the training of future obstetricians, to facilitate the development of basic technical and nontechnical skills, before consolidating these further by supervised clinical practice. We recognise that simulation training does not provide a complete solution; however, there is evidence that it facilitates skills acquisition,[4] which can be further developed by clinical practice to improve real patient outcomes.

In response to the concerns expressed in the Editor's Choice, we would like to advise that simulation training, including the ROBUST Course, is promoted to improve training and skills in operative vaginal birth, in order to improve outcomes for mothers and their babies.


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  • 1
    Tempest N, Hart A, Walkinshaw S, Hapangama D. A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour. BJOG 2013;120:127784.
  • 2
    Dickson M. The role of rotational forceps. BJOG 2013;120:1438.
  • 3
    Mola G. Operative vaginal delivery in the 21st century—a global perspective. In: Attilakos G, Draycott T, Gale A, Siassakos D, Winter C, editors. ROBuST Course Manual. Cambridge: Cambridge University Press; personal correspondence; 2013. pp. 111.
  • 4
    Smith A, Siassakos D, Crofts J, Draycott T. Simulation: improving patient outcomes. Semin Perinatol 2013;37:1516.