Perinatal and Maternal Outcomes After Training Residents in Forceps Before Vacuum Instrumental Birth

To compare the rates of attempted and successful instrumental births, intrapartum cesarean delivery, and subsequent perinatal and maternal morbidity before and after implementing a training intervention to arrest the decline in forceps competency among resident obstetricians.

This retrospective cohort study examined all attempted instrumental births at Monash Health from 2005 to 2014. We performed an interrupted time-series analysis to compare outcomes of attempted instrumental births in 2005-2009 with those in 2010-2014.

There were 72,490 births from 2005 to 2014 at Monash Health, of which 8,789 (12%) were attempted instrumental vaginal births. After the intervention, rates of forceps births increased [autoregressive integrated moving average coefficient (β) 1.5, 95% confidence interval (CI) 1.03-1.96; P<.001], and vacuum births decreased (β -1.43, 95% CI -2.5 to -0.37; P<.01). Rates of postpartum hemorrhage decreased (β -1.3, 95% CI -2.07 to -0.49; P=.002) and epidural use increased (β 0.03, 95% CI 0.02-0.05; P<.001). There was no change in rates of unsuccessful instrumental births (β -0.39, 95% CI -3.03 to 2.43; P=.83), intrapartum cesarean delivery (β -0.29, 95% CI -0.55 to 0.14; P=.24), third- and fourth-degree tears (β -1.04, 95% CI -3.1 to 1.00; P=.32), or composite neonatal morbidity (β -0.18, 95% CI -0.38 to 0.02, P=.08). Unsuccessful instrumental births were more likely to be in nulliparous women (P<.001), less likely to have a senior obstetrician present (P<.001), be at later gestation (P<.001), and involved larger birth weight neonates (P<.001).

A policy of ensuring obstetric forceps competency before beginning vacuum training results in more forceps births, fewer postpartum hemorrhages, and no increase in third- and fourth-degree perineal injuries or episiotomies.