Forceps-Assisted Delivery Could Reduce the Iatrogenic Fistula Crisis: A Clinical Commentary

In an era where the aetiology of childbirth-related pelvic floor fistula is rapidly shifting from ischaemic obstetric fistula to iatrogenic childbirth-related fistula related to complications of caesarean section, strategies must be implemented to minimise the ongoing burden of fistula-related pathologies and surgical morbidity and mortality. Despite growing access to caesarean section in low- and middle-income countries (LMICs), this mode of delivery has introduced new maternal complications such as ureterovaginal and vesico-uterine fistulae that often require abdominal repair. The reintroduction of the safe and skilled use of forceps for delivery in cases of second-stage arrest with the foetal head well below the level of the ischial spines, in particular, cases of intra-uterine foetal demise and exhausted maternal effort, may assist in reducing this trend. In addition to improving surgical training in caesarean section skills, the reintroduction of comprehensive training for vaginal instrumental deliveries including forceps and further emphasis on providing effective obstetric management, may help to improve maternal health care and is urgently needed.