Finally, someone has stepped up to the plate with an article that explains the virtues of operative vaginal delivery. As one of those senior “skilled operators,” I was always shocked to encounter physicians who had completed ObGyn residencies without ever performing a forceps delivery. Imagine an orthopod who has never handled a fracture, an anesthesiologist who never put anyone to sleep! The sorry thing is that the article is addressed not to first-year residents but to board-certified, working ObGyns! These doctors graduated from residency programs that lacked staff experienced in instrumental delivery and thus had no opportunity to learn technique, since forceps can only be learned with hands-on experience. Lawyers have been instrumental in killing this skill.
I want to contribute 2 minor additions to the article. First, there is nothing magical about a right mediolateral episiotomy. Right-handed doctors (most of us) simply find it easier to cut this type of episiotomy. Lefties can cut to the left with the same result. I preferred midline in all situations, but its use seems to vary geographically.
Second, I sometimes used the vacuum extractor in emergency situations when the head of a second twin was presenting, but high. Another strategy in this scenario is giving the mother a couple of whiffs of halothane (or other uterine relaxer), converting the vertex to a breech, and performing a breech extraction. Uterine relaxation is necessary for this—and Piper experience is nice, too! Note that conversion of the vertex to a breech should not be attempted with conduction anesthesia alone; you need an agent that relaxes the uterus. Since nobody has ether anymore, be prepared to use halothane (and insist that the anesthesiologist use what you want). The only other option is cesarean section.
I am afraid instrumental delivery is a lost art, and now, with elective cesarean, perhaps vaginal delivery itself will disappear. Another reason I am glad I limit my practice to gynecology.
Robert Frischer, MD
Wichita Falls, Texas
Dr. Eogan and Dr. O’Herlihy respond:
Training is decisive factor in operative vaginal delivery rates
We appreciate the positive comments of Doctors Friedman and Frischer. In regard to the Kielland forceps, we no longer use this instrument at our unit and thus have limited experience with it.
Our institutional incidence of operative vaginal birth was 12.7% in 2004, with a cesarean section rate of 17% in the same year. Were it not for safe and appropriate training in assisted vaginal delivery, our incidence of cesarean section undoubtedly would be higher. We postulate that the different rates of instrumental delivery, and correspondingly of second-stage cesarean, in the United States may be attributed to differences in residency training programs and trainer and trainee confidence rather than in significant population differences.
While cesarean section plays an important role in modern obstetrics, instrumental delivery remains a safe alternative in the second stage of labor provided its practitioners are appropriately trained.