How capable are SG obstetricians in performing operative vaginal delivery?

The overall rates of neonatal and maternal morbidity with operative vaginal delivery at Singapore General Hospital (SGH) are low, and operators demonstrate proficiency in the use of both forceps and vacuum, according to a recent study. In addition, no direct association is found between the use of instruments and neonatal and maternal complications.

“Operative vaginal delivery remains an essential skill in facilitating safe vaginal delivery, which should be maintained to keep caesarean section rates in check,” the researchers said.

This retrospective study assessed 906 operative vaginal deliveries performed at SGH from 2012 to 2017. The researchers then compared the maternal outcomes in terms of postpartum haemorrhage and obstetric anal sphincter injuries between forceps- and vacuum-assisted deliveries, as well as neonatal outcomes in terms of neonatal intensive care unit (NICU) admission and clinically significant events. Additionally, obstetricians’ instrument preference was analysed.

Of the deliveries included, 461 were forceps- and 445 were vacuum-assisted deliveries. The rate of operative vaginal delivery persisted at about 10 percent from 2012 to 2017. [Singapore Med J 2023;64:313-318]

Neonatal cephalohematomas occurred more frequently following vacuum-assisted deliveries, while other maternal and neonatal outcomes did not significantly differ between the two instrument groups. Clinically significant neonatal events were largely attributable to shoulder dystocia, while cases of NICU admissions were usually not directly linked to the mode of delivery.

Choice of instrument among obstetricians tended to suggest personal preference and was not associated with the year of graduation.

“Although clinicians in our institution often demonstrate a preference for one instrument over another, expertise in both forceps and vacuum is demonstrated by all,” the researchers said.

“Continued training in operative vaginal delivery is a challenge in modern obstetrics owing to widespread deskilling and concerns about its safety and efficacy. In skilled hands, both forceps- and vacuum-assisted deliveries are useful tools in the armamentarium of the obstetrician,” they added.

According to the Royal College of Obstetricians and Gynaecologists Green-top Guideline, obstetricians must show confidence and competence in the use of both forceps and vacuum. Other investigators underscore the role of operator training with the two instruments. [Cochrane Database Syst Rev 2010:CD005455; https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_26.pdf]

“As the use of both instruments is complementary, institutions should maintain a critical mass of obstetricians that can practice both, to preserve the use of both instruments,” the researchers said. “In SGH, each obstetrician demonstrated ability to use both instruments, although some obstetricians did show a clear preference for one instrument over the other.”

This study had certain limitations. First, the differences in outcomes between operative vaginal deliveries and caesarean section performed in the second stage of labour were not evaluated. Second, information about the occurrence of pelvic floor trauma, women’s length of hospital stay, and analgesia use were lacking. Finally, this study was carried out in a single centre only.