There are additional risks associated with the use of sequential instruments during attempted operative vaginal birth.

Althougha failed operative vaginal birth, using a single instrument, such as vacuum extractor, followed by caesarean section, with a normal fetal heart rate trace, does not appear to be associated with poorer neonatal outcomes [11], infants born following the use of second sequential instrument (most commonly forceps following failed ventouse) were more likely to have an umbilical artery pH <7.10 (OR 3.0), and mothers were more likely to sustain an anal sphincter tear (OR 1.8) [12].

Other studies have also demonstrated increased rates of neonatal intracranial haemorrhage following the sequential use of instruments (OR 2.0 in ventouse followed by forceps vs forceps alone) [13].

Rotational births are more likely to fail, particularly using the ventouse cup [14], and this has led to a resurgence in interest in the use of rotational (Kielland) forceps.

Since the publication of the Royal College of Obstetricians and Gynaecologists guideline on Operative Vaginal Birth 2005, there have been a number of publications observing that in UK practice births by Kielland forceps had a rate of adverse maternal and neonatal outcomes comparable to those by rotational ventouse and emergency caesarean section in the second stage for malposition, with a significantly lower failure rate [13].

One recent paper reported: ‘There were no cases of forceps-related neonatal trauma or hypoxic–ischemic encephalopathy and therefore contrary to earlier reports, the use of Kiellands forceps is associated with a high successful delivery rate and apparently low maternal and neonatal morbidity’ [14].

Another study from Scotland observed that: ‘neonatal admission rates after delivery by rotational forceps deliveries (3.3 %) were not significantly different from spontaneous vertex delivery (3.7 %) or ventouse delivery (3.8 %) and lower than emergency caesarean delivery (11.2 %)’ [15].

Clearly, all rotational births can be difficult, and it would be interesting to investigate whether an increase in the use of forceps for rotational births outside a small number of UK centres is either feasible or useful.

All practitioners should be adequately trained to safely and efficiently expedite vaginal birth where required and also garner sufficient experience with a range of techniques. Notably in the UK, junior obstetricians have identified training for rotational births as one of their top three training requirements [15]. Surveys of US obstetricians after finishing residency training showed that trainees needed to perform at least 13 forceps procedures in their 4 years of training in order to be likely to use them in independent practice (positive predictive value 0.83) [16].

However, the exposure of junior obstetricians to operative vaginal birth has declined in the most recent generation of graduates. This has partly been driven by a reasonable reduction in working hours for junior obstetricians during their training. In 1991 in the UK, junior doctors were on duty for an average of 90 h a week [17]; by 2014 this had declined to a theoretical average of 48. This change has been mirrored in most other countries. Moreover, there has been an increase in senior obstetrician presence on the labour ward: in the UK there has been a move after 2005 to increase consultant physical presence to 24 h/day in larger units (>6,000 births/year) [18]. This may have the unintended consequence to further reduce the number of operative vaginal births attempted by junior obstetricians, even though the intention was to increase supervision. Although this may be the case, recent studies published in the UK have demonstrated that rates of senior obstetricians performing more complex births are still low – no more than 20 % in one study of rotational forceps births [19], and so this cannot on its own be responsible for the decline in OVB.

There is also an understandable reluctance by woman to have a complex procedure performed by an inexperienced obstetrician, however, well supervised, and an understandable reticence among other delivery ward staff to expose patients to a junior obstetrician’s learning curve. Therefore, it is vital that obstetricians use other methodologies, primarily simulation-based training, to shorten this learning curve and improve their familiarity and skills in operative.

Training and experience are likely to be symbiotic. Training can be used to teach both individual skills and more complex techniques such that trainees feel able to safely undertake these techniques on the labour ward.

Individual skills can be taught using repetition and instant feedback models – this has been shown to improve the successful placement rate of forceps blades in simulated births from 32 to 70 % [20].

More complex complete procedures can also be effectively taught: the appointment of dedicated operative birth teaching fellows has increased rates of forceps births by 62 % in some US hospitals [21].

There is good evidence that structured obstetric simulation training can improve outcomes – for example, it has been shown to reduce rates of permanent brachial plexus injury following shoulder dystocia [22], low Apgar scores and haemorrhagic ischemic encephalopathy following birth [23].

There are no data investigating changes in clinical outcomes following structured training in operative vaginal birth; however, it is reasonable to extrapolate from other intrapartum training programs that structured simulation-based packages (e.g. RCOG ROBuST training course) could improve outcomes associated with operative birth, but this would be usefully evaluated in a prospective study.

There is a place for operative vaginal birth, performed by well-trained accoucheurs, in selected women.