The role of rotational forceps



The article by Tempest et al.[1] and the response by Dickson,[2] were of particular interest to us, because they raise the question of training and the use of Kiellands forceps (KF).

We recently performed a survey to evaluate the use of KF in Northern Ireland. A web-based survey was targeted at three, age-related, cohorts of obstetricians; namely retired consultants, practising consultants and trainees. In all, 109 responses were obtained, of which 12% represented retired consultants, 51% practicing consultants and 37% trainees.

Although 94% of practicing consultants had experience of using KF, few (22%) currently used them, with 66% feeling ‘uncomfortable’ with their use.

A similar proportion of retired consultants had experience with KF (92%) but in contrast, 82%, when practicing, felt confident with their use. The main reasons stated by existing consultants for not using KF were a ‘lack of training’ and ‘performing too few to maintain skills’, rather than the fear of maternal or neonatal complications or litigation. Eighty-five percent of practicing consultants did not actively train junior staff in the use of KF.

Most trainees (89%) had observed a KF delivery, with 54% having performed at least one under direct supervision. However, the number of procedures performed by trainees was small, and none had used KF independently or felt sufficiently trained to do so. The majority felt that they could not even confidently assess which women might be suitable for rotational forceps delivery. Only 8% felt that they might use them as a consultant.

Over 90% of trainees felt the use of KF was in decline, and lack of adequate training was the most commonly cited reason (92%). A significant proportion seemed to think that this was a regrettable situation, as 81% felt that this decline was ‘important’ and 40% felt strongly that training in the use of KF should form part of the Royal College of Obstetricians & Gynaecologists (RCOG) postgraduate core curriculum. Comments against mandatory training reflected concern over potential difficulty in achieving sufficient opportunity to attain competencies because of the lack of senior staff skilled in the use of KF and prepared to actively teach. Many suggested that training should be mandatory only for those undertaking advanced obstetric training modules.

Tempest et al.[1] conclude that the results of their study ‘should encourage clinicians to re-evaluate their choice of instrument for rotational birth and professional bodies to re-consider training opportunities for this type of birth’, and that within the UK, ‘there are sufficient practitioners to allow a safe phased re-introduction of rotational forceps’. Although we would like to believe this is so, and trainees seem keen to learn, our survey suggests that, at least in our region, the cohort of trainers has declined so much that it may already be too late.

Clearly time is of the essence, but perhaps the RCOG could play a role in preserving the art of using rotational forceps in the United Kingdom.