The changing practice of the obstetrician.

Abstract

The study by Beuckens et al. (BJOG 2015;in press) describes a clinical programme in which midwives were trained to perform external cephalic version (ECV) as part of routine prenatal care. Their overall success rate was 47% following one or more ECV attempts. Nearly three-quarters of the versions were attempted in a primary health care (PHC) setting. Approximately 2.6% of patients experienced fetal death, placental abruption, or preterm birth at any point after ECV in the PHC setting. Although the study design does not allow for a direct comparison with procedures performed exclusively in the inpatient environment, their results highlight that care providers other than obstetricians can be taught to successfully perform ECV; however, larger studies confirming the safety of out-patient ECV without antepartum testing and tocolysis are needed before hospital-based practice should be changed. Although the setting for this study was the Netherlands, where a large proportion of women receive care by midwives with a substantial number of deliveries at home, the training and performance of ECV by midwives and other providers should be considered if appropriately powered prospective randomized trials show no difference in outcomes. Given the shortages of obstetricians in various regions of the world, appropriately trained midwives might be able to offer ECV in regions where obstetricians are in short supply. On a grander scale, however, this work is further evidence of the changing practice of the classically trained obstetrician. Increasingly, procedures that characterised the daily activities of the obstetrician are being performed by other providers or are being eliminated all together. Vaginal breech deliveries are disappearing. Vacuum delivery has supplanted forceps, and may be performed by midwives and family physicians. Twin pregnancies are increasingly being delivered abdominally. These changes in obstetric practice have resulted in an increased rate of caesarean delivery. Although caesarean delivery is usually performed by obstetricians, both qualified surgeons and family medicine physicians can also perform caesarean delivery. With the advent of middle cerebral artery velocimetry for the detection of suspected fetal anaemia and the use of non-invasive prenatal testing for aneuploidy detection, the use of amniocentesis and chorionic villus sampling have declined substantially (Larion et al. Am J Obstet Gynecol 2014;123:651.e1–7). So where does this leave the obstetrician? Perhaps one area where the obstetrician simply cannot be replaced is in providing the obstetrical judgment that comes with their clinical obstetrical experience, detailed knowledge of the history of the field and maternal–fetal physiology, and appreciation of the contemporary scientific literature. Whereas virtually anyone can successfully perform a vaginal delivery, complex pregnancies require the wisdom of a skilled and experienced obstetrician for optimal outcomes; however, this does not negate the need for the specialty of obstetrics to contemplate redefining itself, as the technical skills required to be an obstetrician have so dramatically changed in such a short period of time. Changes in the length of training, the design of training programmes, and the pipeline to subspecialty training should be considered. As the curriculum of medical school education is being restructured, so should the curriculum of obstetrical postgraduate training. No relevant financial or other conflicts of interest.