G. Attilakos, T. Draycott, A. Gale, D. Siassakos, C. Winter (Editors). ROBuST: RCOG Operative Birth Simulation Training. Course Manual. Cambridge University Press, Cambridge, UK, 2013 (Dec). ISBN 9781107680302. Paperback. Price GBP 32.00 (USD 50.00).



Looking back over the 160 years or so, the main method to expedite delivery and get women out of arrested progress at the end of labor, was to apply forceps, an instrument that surely is one of the great inventions of mankind. Some 60 years ago forceps application started to be supplanted by vacuum extraction, another major invention, and oxytocin use and epidurals also came in to benefit women. Delivery at or near full dilatation was and is a manual dexterity “skill”, usually taught by direct instruction from senior to junior. The junior added to his or her personal and accumulating experience, using snippets of advice and common sense to acquire the necessary proficiency. The last decade has seen a move from major textbook reading to lighter texts, guidelines, web-based material and e-learning. In obstetrics a need for teaching of principles in a simulation setting before being “let loose” on real patients, has gained a firm place. Examples are the ALSO and PROMPT programs and laparoscopic training courses.

Now a very useful additon to this has emerged in ROBuST, a comprehensive and very well written manual for trainees accompanying a course with the same name on the topic at the Royal College of Obstetricians and Gynaecologists. While it is surely best to combine course attendance and simultaneous reading of the manual, the latter can in itself be very useful, also for experienced obstetricians, most of whom can admit to themselves that they still can learn and improve. We predict that this initiative will, like the ALSO and PROMPT courses, bring in a renewal of skills with regard to operative vaginal delivery. This is needed because of the alarming recourse to cesarean section, often under difficult circumstances, multiplying immediate and later risks for the mother. Far too much knowledge and experience has in the last decennia become forgotten, not least in the Nordic countries, where forceps use became severely underrated and even frowned upon. Vacuum extraction was adopted instead, but without the adequate back-up principles, as evident in the recent Danish and Swedish postgraduate textbooks on labor management and obstetrics. Another ignored or forgotten principle is that of trial of vaginal delivery in the operating theatre, which is common in the UK but much less so in the Nordic countries. It offers the opportunity of attempting instrumental delivery in controlled circumstances under good analgesia with easy recourse to cesarean section if not successful. This allows thorough examination of the woman abdominally and vaginally and often results in unexpectedly easy instrumental deliveries where the prior assessment was that of possibly difficult delivery and was therefore not attempted in the delivery room. The alternate decision made was to perform cesaren section.

Norway fostered Christian Kielland and Sweden Tage Malmström. We have in our countries average instrumental delivery rates of around 7–8% and approach the WHO recommendation of 15% combined for elective and emergency cesarean sections. Maintaining and improving on that tradition with the evolvement of this or analogue courses is a must in the Nordic countries.

All of the required aspects are covered in a clear and concise text by the 29 contributors, amply illustrated. There is a useful short historical perspective, followed by a chapter on indications and assessment. On the vital topic of descent and rotation progress, the need to determine moulding and edema on the presenting part of the fetal head (“caput succedaneum”) into account is well covered as is the possibility of gathering additional information and support using ultrasound. This is going to be a new part of the obstetric skills acquisition for future obstetricians. However, illustrations on the fetal head station would have been helpful because determing the fetal head station is still one of the most difficult aspects of instrumental deliveries. This is often a source of confusion, as many believe it is the biparietal diameter that should be at the level of the ischial spines to allow for a safe instrumental delivery, whereas it is in fact the presenting bony point (usually the occiput) which should be at the spines and then the broadest part of the fetal head, the biparietal diameter, should have passed the pelvic inlet, as confirmed by palpating the fetal head abdominally.

The chapter on human relations in the labor room, the “non-technical skills”, could have placed more weight on team approach and division of responsibilities between different staff. Leadership of the obstetrician could have been better covered. The chapters on vacuum extraction and non-rotational/rotational forceps are lucid and inspiringly written. The chapter on the alternative of cesarean section at full dilatation holds the same promise, and there are good chapters on medico-legal matters and relevant analgesia/anesthesia.

For seniors like the undersigned, the book is an evening's reading. The trainee may take a little longer, require discussion in a good group led by someone experienced, but all will be gripped by enthusiasm and a resolve to do better.