Forceps delivery: potential benefits and a call for continued training

Obstetricians, charged with providing optimal care for women and their babies, are at a crossroads. The cesarean delivery rate continues to increase in the United States, with 30.2% of all births in 2005 via cesarean.¹ In addition, the primary cesarean rate, 20.6% of all deliveries in 2004, continues to climb, continuing the trend of annual 5% increases.² More than 20% of cesarean deliveries for dystocia are performed during the second stage of labor.³ Operative vaginal deliveries comprise approximately 9 to 12% of all deliveries, with decreasing frequency in recent reports.^{4, 5, 6} Importantly, operative vaginal delivery, using a single instrument, affords no increased risk of major neonatal injury compared with cesarean. For instance, in a study of nearly 600 000 births in California, intracranial hemorrhage was not increased in neonates delivered by forceps or vacuum compared with those delivered by cesarean.⁶

Operative vaginal delivery, however, is not without risk of maternal morbidity. Risk of third or fourth degree perineal laceration is increased with operative vaginal delivery.⁷ Less clear are the risks of urinary and fecal incontinence in those undergoing operative vaginal delivery compared with cesarean during the second stage of labor. Although vaginal delivery appears to increase the risk of incontinence in the short-term postpartum period, it is not clear whether the increased risk persists throughout a woman's lifetime.^{8, 9, 10, 11} Thus, increased risk of maternal soft tissue injury and an unclear risk of incontinence must be weighed against the known risks of cesarean. Compared with vaginal birth, cesarean has been linked to longer hospitalization, increased risks of thromboembolism and infection, and higher rates of postpartum maternal death.¹² In addition, women with a primary cesarean who plan on future children are more than 90% likely to deliver via repeat cesarean with its concomitant risks.² Further, in these subsequent pregnancies, there are increased risks of placenta previa and unexplained intrauterine fetal death (IUFD).^{13, 14} Thus, without neonatal benefit and the potential for increased morbidity from repeat cesarean delivery, operative vaginal delivery may confer the least maternal and neonatal risk.

The choice of instrument for operative vaginal delivery is determined by several factors, including concern for maternal and neonatal morbidity, chance of success and operator expertise. Vacuum-assisted deliveries are associated with increased rates of neonatal cephalohematoma and retinal hemorrhage.⁷ Further, it has been noted that the rate of shoulder dystocia is higher with vacuum-assisted deliveries.^{15, 16} In addition, the chance of a failed operative delivery using vacuum is almost two times greater than with forceps.⁷ Despite all of these considerations, it may be the last one, operator expertise, which ultimately determines the instrument of choice for many clinicians. Likely owing to this last factor, the proportion of operative vaginal deliveries which are forceps has fallen over the past decade.^{4, 5, 6}

In this issue of the Journal of Perinatology, Dr Powell et al.¹⁷ report that only about half of graduating fourth year residents responding to a survey felt competent in forceps-assisted deliveries. Interestingly, the vast majority of respondents wished to be further trained to perform forceps deliveries. However, whereas more than 80% of respondents stated that most of their attending physicians would teach the use of the vacuum, only one-third of respondents reported that most of their attending physicians would teach the use of forceps. We assert that these statistics are unacceptable and will not guarantee a generation of skilled practioners with the tools necessary to delivery optimal obstetrical care, which is in our patients' best interest. We would equate the inadequacy of such training to surgical residents not being trained in laparoscopy or radiologic residents not being trained to read an MRI. In both cases there are other technologies or options of care available but, depending on the clinical scenario, one particular technique may prove optimal. For residency programs where only a minority of attending physicians are capable to teach the use of forceps, we recommend the use of sophisticated simulators for residents to become comfortable with the basics of forceps application and traction. We have a duty to women to train obstetricians skilled in the art of operative vaginal delivery to help staunch the increasing trend toward cesarean delivery for all but the most straightforward vaginal deliveries.