Objective
The objective of the study was to evaluate the impact on resident forceps experience by a single proactive teacher.
Study Design
A study was performed to assess the impact on delivery statistics and outcome following the assignment of a single attending to teach forceps to residents. A 2 year period immediately preceding and 2 years following the study was compared using χ 2 and Student t tests.
Results
After appointment of the specific teaching attending, forceps deliveries increased by 59% (8% of all births), whereas vacuum procedures decreased to 3% of births ( P < .0001) compared with the prior 2 years. The overall percentage of operative vaginal deliveries remained unchanged (11%). Cesarean section rates were unchanged during the study period at 27% of all births. Perineal laceration, 5 minute Apgar less than 7, and birth injuries were also not statistically different. There were fewer fetal pH events less than 7.1 in the teaching period ( P = .003).
Conclusion
In the population studied, there was an association between increasing resident forceps use and a positive impact on birth outcomes from the designation of a full-time, experienced, and proactive faculty member to obstetrics teaching duty.
The first accounts of therapeutic instruments being used for vaginal delivery of an intact fetus were those of the Chamberlen family in England. Between 1600 and 1728, they developed a highly regarded reputation as accoucheurs up to and including the royal family based greatly on their development of a 2-bladed, separable, fenestrated forceps with a cephalic curve. As Hugh Chamberlen Sr, wrote in 1670, we have “long practiced a way to deliver women in this case, without any prejudice to them or their infants; although all others do, and must endanger, if not destroy 1 or both.” Forceps rapidly became the distinguishing skill and art of the developing field of obstetrics in the ensuing centuries.
Forceps utilization in the United States reached a peak during the mid-20th century, accounting in some reports for two thirds of all deliveries performed. However, since then, there has been a steady decline in use as well as in teaching of residents in training. A series of survey reports have documented a worrisome decline in forceps teaching. Bofill et al have reported that trained American College of Obstetricians and Gynecologists (ACOG) fellows were less likely to use forceps in favor of vacuum devices, perhaps reflecting either a lack of familiarity or training with forceps in particular or operative vaginal delivery in general.
This decline in forceps utilization is associated with an increase in cesarean section, fear of litigation, and regionally variable practice patterns. Although forceps applied by a trained obstetrician in the appropriate patient is without question a safe and effective means of delivering the fetus, there are lingering concerns that the fetus and/or mother will be injured unnecessarily. This concern has partly resulted in the United States having a cesarean section rate greater than that of most other highly developed nations. However, a report by Johanson et al that followed up a group of 306 women for 5 years following a forceps delivery reported that there was no apparent long-term impact to either mother or fetus.
This study was undertaken to evaluate whether a change in the experience and practice patterns of the faculty attending in the labor and delivery division (L&D) would result in a significant change in the experience residents had with forceps. We speculated that resident experience was built on the foundation of the practice style embodied by the attending charged with clinical teaching. We therefore hypothesized that assigning a faculty member with a proactive attitude toward forceps to L&D duty would result in a measurable and significant increase in resident forceps utilization rates.
Materials and Methods
In compliance with Accreditation Council for Graduate Medical Education and Residency Review Committee requirements for continuous faculty staffing in the L&D division, a senior generalist obstetrician with 35 years’ clinical experience was recruited to provide daytime L&D coverage, which involved responsibility for all births. The faculty member was charged with ensuring high quality obstetrical care. Teaching of all aspects of obstetrical management was expected but in particular the appropriate use of instrumental assisted delivery. The attending physician worked as the L&D laborist 4 days daily and performed night call approximately 2-3 times per month.
Other than the recruitment of this specific individual, there were no other changes made in the training program or in L&D, especially with regard to operative vaginal delivery. All other faculty who provided L&D coverage (nights and weekends) made clinical decisions independently without influence as to choice of instrument. Members of the general (6 faculty) and maternal-fetal medicine (7 faculty) divisions provided this night and weekend teaching and supervision duty in rotation.
Resident trainees were at all times under the active direction of their faculty and thus were under the influence of the faculty on duty as to choice of instrument. Generally second and third year residents performed all operative vaginal delivery procedures. The patient population demographics did not appreciably change during the period of study, and informed consent was obtained for all procedures prior to placement except in clinically urgent cases in which explicit formal consent was not practicable.
We performed a retrospective cohort analysis of the L&D database for the 2 years immediately preceding and 2 years immediately following (during employment) assignment of the laborist to L&D.
The deliveries occurred at a tertiary care academic urban teaching hospital staffed full-time by a team of obstetrician-gynecologist residents and a member of the faculty in an attending obstetrician role. All delivery events during the 4 year period were included, and without exception the residents were involved in all deliveries. Assisted vaginal delivery was performed as per ACOG guidelines.
Delivery outcome variables analyzed included third- and fourth-degree laceration, fetal injury noted at birth (defined as fracture, laceration or palsy), 5 minute Apgar less than 7, and fetal pH less than 7.1.
This study was ruled exempt by the institutional review board. Statistical analysis was performed with χ 2 or Student t test as appropriate. Statistical software (Datamaster; RRR, Moscow, Russia) was utilized for calculations. Statistical significance was established at P < .05.
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