It is always reassuring to find that the conclusions made in a contemporary article in a biomedical journal mirror the conclusions and decision made in a judicial review. Tempest et al. recently reported on over 1200 forceps, ventouse, or manual rotations performed in mothers with arrest of descent, with the fetal head not in an occiput anterior position (BJOG 2013;120:1277–84). They conclude that ‘assisted vaginal birth by Keilland forceps is likely to be the safest and most effective’ mode of delivery. In 2007 the Scottish Court of Sessions ruled in a case in which a transverse arrest of descent was treated with a trial of rotational forceps that failed (Dinley versus Lothian Health Board). The birth was completed abdominally and the baby went on to develop encephalopathy, and ultimately, cerebral palsy. The plaintiff alleged negligence both in the decision to try a forceps rotation and the conduct of the operation itself. Lord Hodge weighed the evidence and expert opinions, and concluded that even though some experts consider that a trial of forceps was not appropriate, a substantial volume of medical literature supports this approach as safe and effective. Moreover, the excellent documentation by the operating clinician established that the requirements for such a rotational delivery to be appropriate had been met, and the procedure was performed properly. The doctor and health facility were found not guilty of negligence.
Both the justice system and Tempest et al. have identified the prerequisites for a forceps rotation to be justifiable. These include: an experienced operator, adequate anaesthesia, certainty of fetal position and station, and access to acute emergency abdominal delivery and neonatal resuscitation. In my hospital, these can only be achieved by moving the mother to an operating room, having anaesthesia and paediatric teams present, and being prepared to abandon the attempt at forceps delivery if it proves to be too difficult. We duplicate the old ‘double set–up’ approach used in the days before the antepartum diagnosis of placenta praevia could be made easily, so we are under no pressure to complete the delivery with forceps.
So, given this alignment of solicitors and surgeons, why are fewer and fewer forceps operations attempted in contemporary practice? MJ Dickson, in his letter regarding the Tempest paper (BJOG 2013;120:1438), highlighted the problems. As a surgical procedure is attempted less and less, collective experience wanes, as does confidence and competence. With fewer competent and confident practitioners as models, learners are not exposed to success and thus ‘lack the training’ to attempt the procedure. Before this valuable tool in the work box of the accoucheur is relegated to the ‘dustbin of history’ we must actively bring it back into practice. This is a moment amidst free fetal DNA and epigenetics for senior obstetricians to shine. Those of us with competence and confidence need to take advantage of the teaching experiences beckoning in labour and delivery. Ian Treharne presents the intriguing idea of a ‘Keilland forceps club’ (letter in this issue), with an experienced mentor to enhance clinical training. Perhaps every institution needs one?