Rotational Forceps Delivery Research Articles

Maternal and Neonatal Complications Following Kielland's Rotational Forceps Delivery: A Systematic Review and Meta-analysis

(Abstracted from BJOG 2023;130:856–864) Fetal malposition as labor advances can contribute to many risks and adverse outcomes. One method of management is Kielland rotational forceps delivery (KRFD); previous research has yielded conflicting evidence about the safety and effectiveness of KRFD compared with other delivery methods.

The Art of Kielland rotational forceps delivery. Do we need more training or should we abandon it? That is the question: A retrospective observational study

The Art of Kielland rotational forceps delivery. Do we need more training or should we abandon it? That is the question: A retrospective observational study

Maternal and neonatal complications following Kielland's rotational forceps delivery: A systematic review and meta-analysis.

There is conflicting evidence regarding the safety of Kielland's rotational forceps delivery (KRFD) in comparison with other modes of delivery for the management of persistent fetal malposition in the second stage of labour. To derive estimates of risks of maternal and neonatal complications following KRFD, compared with rotational ventouse delivery (RVD), non-rotational forceps delivery (NRFD) or a second-stage caesarean section (CS), from a systematic review and meta-analysis of the literature. Standard search methodology, as recommended by the Cochrane Handbook for Systematic Reviews of Interventions. Case series, prospective or retrospective cohort studies and population-based studies. A meta-analysis using a random-effects model was used to derive weighted pooled estimates of maternal and neonatal complications. Thirteen studies were included. For postpartum haemorrhage there was no significant difference between Kielland's and ventouse delivery; the rate was lower in Kielland's delivery compared with non-rotational forceps (RR0.79, 95%CI 0.65-0.95) and second-stage CS (RR0.45, 95%CI 0.36-0.58). There were no differences in the rates of anal sphincter injuries or admission to neonatal intensive care. Rates of shoulder dystocia were higher with Kielland's delivery compared with ventouse delivery (RR1.79, 95%CI 1.08-2.98), but rates of neonatal birth trauma were lower (RR0.49, 95%CI 0.26-0.91). There were no differences seen in the rates of 5-min APGAR score < 7 between Kielland's delivery and other instrumental births, but they were lower when compared with second-stage CS (RR0.47, 95%CI 0.23-0.97). Kielland's rotational forceps delivery is a safe option for the management of fetal malposition in the second stage of labour.

Mitigating the stress of transition: An exploration of the effects and effectiveness of a preparatory course for junior obstetric trainees transitioning to senior training roles

BackgroundAttrition amongst obstetrics trainees is high worldwide and attributed to sources of stress and burnout. The role of formal education and simulation as a means to prepare trainees for stressful periods such as transition into senior roles is underexplored. ObjectiveThis study set out to explore whether the creation of a dedicated educational intervention might positively influence burnout and self-estimated preparedness for practice among obstetric trainees transitioning into more senior roles. Study designA six-week preparatory training programme for year 2 trainees was created specifically for this study. The intervention used the flipped classroom design incorporating online learning that prepared participants for six simulation-based workshops. Participants were randomised by training cluster into an intervention group (n = 4) who participated in the educational intervention and a control group (n = 7) who received standard online and workplace training. The effects on trainee well-being was assessed using the Maslach burnout inventory (MBI) and a self-report questionnaire estimating preparedness for practice. Technical and non-technical skills were assessed using standardised OSAT and NOTSS assessment tools. The primary outcomes were MBI and preparedness for practice scores. Secondary outcomes included OSAT and NOTSS scores. Group comparisons were made using by t-test or Pearson Chi2 analysis where appropriate. ResultsThe study indicated a positive, non-significant trend in pre-post burnout scores in the intervention group. The following improving trends were noted in all subscales: emotional exhaustion 21.5 ± 2.6 (pre-intervention 23 ± 6.2); depersonalisation 9.8 ± 4.0 (pre-intervention 12.3 ± 2.8); personal accomplishment 35.5 ± 6.51 (pre-intervention 33 ± 5.5). The educational intervention engendered an increase in self estimated preparedness for practice amongst the intervention group (p = 0.006). From a training perspective, increased preparedness was noted for the following practical skills: forceps delivery (p = 0.0001), rotational forceps delivery (p = 0.02), delivery of twins vaginally (p = 0.0007) and performing a pudendal block (p = 0.001). ConclusionThis is one of the first studies to investigate whether the provision of a targeted training module can improve burnout scores and preparedness for practice amongst obstetrics trainees at an important time of transition. The positive but largely non-significant findings of this study should be examined in larger longitudinal and adequately powered studies.

Comparison of Perinatal Outcomes for All Modes of Second Stage Delivery in Obstetric Theaters: A Retrospective Observational Study

(BJOG. 2021;128:1248–1255) The World Health Organization recommend techniques to encourage vaginal delivery to mitigate unnecessary cesarean deliveries and the associated complications. These techniques include Keilland’s rotational forceps delivery, direct forceps delivery, manual rotation followed by forceps delivery, or ventouse delivery. Although this study demonstrated that Keilland’s rotational forceps delivery may be associated with successful vaginal delivery, some clinicians currently avoid instrumental delivery to evade maternal or neonatal harm, which ultimately leads to less skilled instrumental delivery and therefore, a riskier alternative. This study evaluated the effectiveness and safety of instrumental vaginal delivery techniques. In addition, it compared adverse perinatal outcomes between instrumental delivery and primary emergency cesarean section at full dilation (pEmCS).

Kielland’s rotational forceps delivery: comparison of maternal and neonatal outcomes with pregnancies delivering by non-rotational forceps

We compared complications in pregnancies that had Kielland’s rotational forceps delivery (KRFD) with non-rotational forceps delivery (NRFD). Maternal outcomes included post-partum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS); neonatal outcomes included admission to neonatal intensive care unit (NICU), 5-minute Apgar scores <7, hypoxic ischaemic encephalopathy (HIE), jaundice, shoulder dystocia and birth trauma. The study population included 491 (2.1%) requiring KRFD, 1,257 (5.3%) requiring NRFD and 22,111 (93.0%) that had SVD. In pregnancies with NRFD compared to KRFD, there was higher incidence of OASIS (8.5% vs. 4.7%; p = .006) and a non-significant increased trend for PPH (15.0% vs. 12.4%; p = .173). There was no significant difference in rates of admission to NICU (p = .628), 5-minute Apgar score <7 (p = .375), HIE (p = .532), jaundice (p = .809), severe shoulder dystocia (p = .507) or birth trauma (p = .514). Our study demonstrates that KRFD has lower rates of maternal complications compared to NRFD whilst the rates of neonatal complications are similar. IMPACT STATEMENT What is already known on this subject? Kielland’s rotational forceps is used for achieving vaginal delivery in pregnancies with failure to progress in second stage of labour secondary to fetal malposition. The use of Kielland’s forceps has significantly declined in the last few decades due to concerns about an increased risk of maternal and neonatal complications, despite the absence of any major studies demonstrating this increased risk. What do the results of this study add? There are some studies which compare the risks in pregnancies delivering by Kiellands forceps with rotational ventouse deliveries but there is limited evidence comparing the risks of rotational with non-rotational forceps deliveries. Our study compares the major maternal and neonatal complications in a large cohort of pregnancies undergoing rotational vs. non-rotational forceps deliveries. What are the implications of these findings for clinical practice and/or further research? The results of our study demonstrate that maternal and neonatal complications in pregnancies delivering by Kielland’s rotational forceps undertaken by appropriately trained obstetricians are either lower or similar to those delivering by non-rotational forceps. Consideration should be given to ensure that there is appropriate training provided to obstetricians to acquire skills in using Kielland’s forceps.

Kielland’s rotational forceps delivery: A comparison of maternal and neonatal outcomes with rotational ventouse or second stage caesarean section deliveries

ObjectivesThe objective of our study was to derive accurate estimates of risks of maternal and neonatal complications associated with Kielland’s rotational forceps delivery (KRFD) compared to rotational ventouse delivery (RVD) or 2nd stage caesarean section (CS). MethodsThis was a retrospective cohort study undertaken at a large tertiary maternity and neonatal unit in the United Kingdom between January 2010 and June 2018. Pregnancies with fetal demise, major fetal defects, those lost to follow-up, those delivering by elective or emergency CS in the first stage of labour and non-rotational instrumental deliveries were excluded. The study population included singleton pregnancies delivering by Kielland’s forceps, rotational ventouse, 2nd stage CS or spontaneous unassisted cephalic vaginal delivery; the latter forming the control group. The maternal outcomes examined included post-partum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS). The neonatal outcomes included admission to neonatal intensive care unit (NICU), 5-minute Apgar scores <7, hypoxic ischaemic encephalopathy (HIE), jaundice, shoulder dystocia and birth trauma. Absolute risks with 95 % confidence intervals (CI) were calculated in the study groups. Univariate and multivariate logistic regression analysis was carried out to estimate crude and adjusted odds ratio (OR) with 95 % CI. ResultsThe study population of 23,786 pregnancies included: 491 (2.1 %) requiring KRFD, 344 (1.4 %) requiring RVD, 840 (3.5 %) that had a 2nd stage CS and 22,111 (93.0 %) spontaneous cephalic vaginal deliveries. With regard to maternal adverse outcomes, in pregnancies that had a KRFD compared to RVD, there was no significant difference in the incidence of OASIS (p = 0.599) or PPH (p = 0.982). In contrast, the risk of PPH was significantly higher in those delivering by a 2nd stage CS compared to KRFD (27.5 % vs. 12.4 %; p < 0.0001). With regard to neonatal adverse outcomes, in those delivering by KRFD compared to RVD and 2nd stage CS, there was no significant difference in the incidence of admission to NICU (p = 0.912; p = 0.746, respectively), 5-minute Apgar score<7 (p = 0.335; p = 0.150, respectively), jaundice (p = 0.810; p = 0.332, respectively), mild shoulder dystocia (p = 0.077), severe shoulder dystocia (p = 0.603) or birth trauma (p = 0.265; p = 0.323, respectively). The risk of maternal composite adverse outcome was highest after 2nd stage CS (OR 7.68; 95 %CI: 6.52−9.04) and lowest after KRFD (OR 3.82; 95 %CI: 2.98−4.91). The risk of composite neonatal adverse outcome was higher in those delivering by RVD (OR 2.87; 95 %CI: 2.10−3.91), compared to KRFD (OR 2.23; 95 %CI: 1.67−2.97) or 2nd stage CS (OR 2.02; 95 %CI: 1.60−2.54). ConclusionOur study demonstrates that KRFD is a safer management option when compared to RVD or 2nd stage CS for the management of persistent fetal malposition in labour.

Intrapartum ultrasound during rotational forceps delivery: a novel tool for safety, quality control, and teaching

Operative vaginal delivery and, in particular, rotational forceps delivery require extensive training, specific skills, and dexterity. Performed correctly, it can reduce the need for difficult late second-stage cesarean delivery and its associated complications. When rotation to occiput anterior position is achieved, pelvic trauma and anal sphincter injury commonly associated with direct delivery from occiput posterior positions may be avoided. We report the original and novel use of real-time intrapartum ultrasound simultaneously during Kielland's rotational forceps delivery to monitor correct execution and increase maternal safety. This is a prospective observational study performed at the Charité University Hospital in Berlin between 2013 and 2018. Simultaneous, real-time, intrapartum suprapubic ultrasound during Kielland's rotational forceps deliveries were performed in a series of laboring women with normal fetuses and arrest of labor in the late second stage and with a fetal head malposition, requiring operative vaginal delivery. In addition to vaginal palpation for head station, rotation, and asynclitism, intrapartum ultrasound was also used to objectively determine head station, head direction, and midline angle. The operator was not blinded to the ultrasound findings. The delivering obstetrician examined the woman and performed the delivery. An assistant, trained in intrapartum ultrasound, placed a curved-array transducer transversely in the midline just above the pubic bone to display the forceps blades being applied and the rotation of the fetal head in occiput anterior position. In all 32 laboring women included in the study, the blades were applied correctly and the fetal heads successfully rotated to an occiput anterior position with direct ultrasound confirmation, and vaginal delivery was achieved. There were no cases of difficult application, repeat application, slippage of the blades, or rotation of the fetal head in the wrong direction. Maternal outcomes showed no vaginal tears, cervical tears, or postpartum hemorrhage >500 mL. There was 1 case of third-degree perineal tear (3a). Neonatal outcomes included mild hyperbilirubinemia (n=1), small cephalohematoma conservatively managed (n=1), and early-onset group B streptococcus sepsis secondary to maternal colonization (n=1). There were no neonatal deaths. Ultrasound guidance during Kielland's rotational forceps delivery is an original and novel approach. We describe the use of intrapartum ultrasound in assessing fetal head station and position and also to simultaneously and objectively monitor performance of rotational forceps delivery. Intrapartum ultrasound enhances operator confidence and, possibly, patient safety. It is a valuable adjunct to obstetrical training and can improve learning efficiency. Real-time ultrasound guidance of fetal head rotation to occiput anterior position with Kielland's forceps may also protect the perineum and reduce anal sphincter injury. This novel approach can lead to a renaissance in the safe use of Kielland's forceps.

OC05.01: Rotational forceps delivery: a novel role of intrapartum ultrasound for quality control and teaching

OC05.01: Rotational forceps delivery: a novel role of intrapartum ultrasound for quality control and teaching

Looking back: sectio in mortua and the role of the midwife

Operative vaginal delivery and, in particular, rotational forceps delivery require extensive training, specific skills, and dexterity. Performed correctly, it can reduce the need for difficult late second-stage cesarean delivery and its associated complications. When rotation to occiput anterior position is achieved, pelvic trauma and anal sphincter injury commonly associated with direct delivery from occiput posterior positions may be avoided.We report the original and novel use of real-time intrapartum ultrasound simultaneously during Kielland’s rotational forceps delivery to monitor correct execution and increase maternal safety.This is a prospective observational study performed at the Charité University Hospital in Berlin between 2013 and 2018. Simultaneous, real-time, intrapartum suprapubic ultrasound during Kielland’s rotational forceps deliveries were performed in a series of laboring women with normal fetuses and arrest of labor in the late second stage and with a fetal head malposition, requiring operative vaginal delivery. In addition to vaginal palpation for head station, rotation, and asynclitism, intrapartum ultrasound was also used to objectively determine head station, head direction, and midline angle. The operator was not blinded to the ultrasound findings.The delivering obstetrician examined the woman and performed the delivery. An assistant, trained in intrapartum ultrasound, placed a curved-array transducer transversely in the midline just above the pubic bone to display the forceps blades being applied and the rotation of the fetal head in occiput anterior position.In all 32 laboring women included in the study, the blades were applied correctly and the fetal heads successfully rotated to an occiput anterior position with direct ultrasound confirmation, and vaginal delivery was achieved. There were no cases of difficult application, repeat application, slippage of the blades, or rotation of the fetal head in the wrong direction. Maternal outcomes showed no vaginal tears, cervical tears, or postpartum hemorrhage >500 mL. There was 1 case of third-degree perineal tear (3a). Neonatal outcomes included mild hyperbilirubinemia (n=1), small cephalohematoma conservatively managed (n=1), and early-onset group B streptococcus sepsis secondary to maternal colonization (n=1). There were no neonatal deaths.Ultrasound guidance during Kielland’s rotational forceps delivery is an original and novel approach. We describe the use of intrapartum ultrasound in assessing fetal head station and position and also to simultaneously and objectively monitor performance of rotational forceps delivery. Intrapartum ultrasound enhances operator confidence and, possibly, patient safety. It is a valuable adjunct to obstetrical training and can improve learning efficiency. Real-time ultrasound guidance of fetal head rotation to occiput anterior position with Kielland’s forceps may also protect the perineum and reduce anal sphincter injury. This novel approach can lead to a renaissance in the safe use of Kielland’s forceps.

Kielland's forceps: does it increase the risk of anal sphincter injuries? An observational study.

Rotational instrumental deliveries are thought to carry additional risks compared with non-rotational instrumental deliveries, including trauma to maternal tissues, and require specific expertise and training. We conducted a retrospective study to investigate the association between the type of forceps delivery and maternal perineal trauma, and in particular to investigate if Kielland's rotational forceps delivery increases obstetric anal sphincter injuries (OASIS). This is a retrospective observational study of 1,515 women who attended a tertiary maternity unit over a period of 5 years and had operative vaginal deliveries primarily or completed by forceps. Data were obtained through the hospital's maternity reporting system. The severity of maternal perineal trauma, particularly third and fourth-degree tears in relation to the type of forceps delivery was explored. Multinomial logistic regression models were used to estimate the crude and the adjusted relative risks (RR) of sustaining third-degree tears compared with other types of vaginal tears. Univariate analyses explored the crude associations between relative risks and age, ethnicity, birth weight, type of instrumental delivery and operator's experience. A multivariate multinomial logistic regression model estimated the adjusted relative risks and included all the previous variables as independent covariates. Of the 1,492 women included in the study, 150 women (77 %) had sustained category 1 tears, 63 women (4 %) had sustained category 2 tears and 279 women (19 %) had sustained third-degree tears. There was no statistically significant association between the severity of maternal perineal trauma and the type of forceps delivery (failed ventouse vs Kielland's forceps RR 1.52, p = 0.159 CI 0.84-2.72, Wrigleys vs Kielland's RR 0.59, p = 0.249, CI 0.24-1.43; Andersons vs Kielland's RR 1.16, p = 0.603, CI 0.65-2.05) after adjusting for age, birth weight, BMI, ethnicity and operator experience (full list of covariates not included). The incidence of third- and fourth-degree tears following rotational Kielland's forceps delivery and other non-rotational forceps deliveries is comparable.

Learning From Experience: Qualitative Analysis to Develop a Cognitive Task List for Kielland Forceps Deliveries.

Fetal malposition is a common indication for Caesarean section in the second stage of labour. Rotational (Kielland) forceps are a valuable tool in select situations for successful vaginal delivery; however, learning opportunities are scarce. Our aim was to identify the verbal and non-verbal components of performing a safe Kielland forceps delivery through filmed demonstrations by expert practitioners on models to develop a task list for training purposes. Labour and delivery nurses at three university-affiliated hospitals identified clinicians whom they considered skilled in Kielland forceps deliveries. These physicians gave consent and were filmed performing Kielland forceps deliveries on a model, describing their assessment and technique and sharing clinical pearls based on their experience. Two clinicians reviewed the videos independently and recorded verbal and non-verbal components of the assessment; thematic analysis was performed and a core task list was developed. The algorithm was circulated to participants to ensure consensus. Eleven clinicians were identified; eight participated. Common themes were prevention of persistent malposition where possible, a thorough assessment to determine suitability for forceps delivery, roles of the multidisciplinary team, description of the Kielland forceps and technical aspects related to their use, the importance of communication with the parents and the team (including consent, debriefing, and documentation), and "red flags" that indicate the need to stop when safety criteria cannot be met. Development of a cognitive task list, derived from years of experience with Kielland forceps deliveries by expert clinicians, provides an inclusive algorithm that may facilitate standardized resident training to enhance education in rotational forceps deliveries.

Kielland's forceps: demise before the 100th anniversary?

To the Editor: As the time for the centennial of the Kielland’s forceps approaches, one ponders: will this elegant instrument have its demise before its 100th anniversary? Introduced in 1915 by Dr Christian Kielland, a Norwegian obstetrician, for the “deep transverse arrest,” it evolved into the instrument of choice for arrest of descent with occipito-transverse or occipito-posterior position of a cephalic presentation.1.Patterson W.R. The Kielland forceps.Can Med Assoc J. 1928; 18: 177-180PubMed Google Scholar The malpresenting baby would often not be large, as opposed to a non-malpresenting baby that would usually be large to have arrested in the first place. With a high likelihood of failure with attempts at manual rotation or a rotational vacuum, the Kielland’s forceps became an ideal instrument for facilitating a vaginal birth for fetal malposition in cephalic presentation. The relatively straight handle with a gentle backward pelvic curve and a sliding lock were ingenious additions to the obstetric forceps design, allowing easy application to a severely asynclitic head. Further, this design, when combined with the Scanzoni manoeuvre, allowed rotation of up to 180 degrees within the tight constraints of the maternal pelvis due to a relatively small circle of rotation. Given the usual normal-sized baby being delivered, once the head could be successfully rotated, most skilled users would agree that the risk of a significant perineal laceration was small. However, the last decade has witnessed a rapid decline in the use of Kielland’s forceps.2.Ramin S.M. Little B.B. Gilstrap 3rd., L.C. Survey of forceps delivery in North America in 1990.Obstet Gynecol. 1993; 81: 307-311PubMed Google Scholar, 3.Vacca A. Current obstetric training programs are unlikely to provide registrars with sufficient skill in the safe use of Kielland forceps.Aust N Z J Obstet Gynaecol. 2000; 40: 226-227Crossref PubMed Google Scholar This can be attributed to concerns regarding poor neonatal outcomes that were associated with the use of Kielland’s forceps.4.Patel R.R. Murphy D.J. Forceps delivery in modern obstetric practice.BMJ. 2004; 328: 1302-1305Crossref PubMed Scopus (95) Google Scholar In the litigious field of obstetrics, it was tempting to give up a controversial practice for the easier option, the Caesarean section. Given the medico-legal climate, although North American centres were slow in adopting the use of Kielland’s forceps, they were quicker to let it go. However, more recent evidence suggests that the concerns regarding neonatal outcomes may have been misplaced. A retrospective review of deliveries at a tertiary care centre over a four-year period compared the use of Kielland’s forceps, rotational ventouse and emergency Caesarean section.5.Tempest N. Hart A. Walkinshaw S. Hapangama D.K. A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour.BJOG. 2013; 120: 1277-1284Crossref PubMed Scopus (72) Google Scholar With a 25% Caesarean section rate and a 13% operative vaginal delivery rate, a cohort of approximately 1300 cases that reached full cervical dilatation with fetal malposition was identified. With an intention-to-treat analysis, 80% had an attempted Kielland’s rotation, 8% had an attempted rotational ventouse, and 11% had an emergency Caesarean section. The likelihood of needing a Caesarean section was eight-fold higher if a ventouse was used as opposed to the Kielland’s forceps. Failure of delivery with Kielland’s occurred in 4% of cases. Other than a trend towards an increased rate of shoulder dystocia, no increase in adverse outcomes was noted.5.Tempest N. Hart A. Walkinshaw S. Hapangama D.K. A re-evaluation of the role of rotational forceps: retrospective comparison of maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour.BJOG. 2013; 120: 1277-1284Crossref PubMed Scopus (72) Google Scholar However, obstetric practice changed before the evidence relating to the long-term outcomes of babies could become available,6.Kotaska A. Menticoglou S. Gagnon R; SOGC Maternal Fetal Medicine Committee. Vaginal delivery of breech presentation. SOGC Clinical Practice Guideline no. 226, June 2009.J Obstet Gynaecol Can. 2009; 31 (567–78): 557-566Abstract Full Text PDF PubMed Scopus (72) Google Scholar leaving a generation of obstetricians who are untrained in the science and art of a rotational forceps delivery. With increasing Caesarean section rates and associated maternal morbidity and mortality, we need ongoing efforts to find viable alternatives to Caesarean section. This leads to the question: is it time to revive the Kielland’s forceps delivery before it is too late? Or should we helplessly watch this endangered species disappear and become a part of the annals of the history of medicine?

The Rise and Decline of Operative Obstetrics or, the Joys of a Peripatetic Obstetrician

I awoke and it was a dream. This has encouraged me to share with you the joys of a peripatetic obstetrician who spent more than 40 years practising obstetrics when obstetrics, particularly operative obstetrics, truly was an Art. Sadly this is no longer the case, although one could, if one had the necessary experience, still practise this kind of obstetrics in a developing country where the patient would bless you for having saved her child and for having preserved her from a feared Caesarean section. It is almost impossible to convey the sense of achievement, joy and wonder when, bathed in sweat, after a difficult rotational forceps or breach delivery, one stands gazing at a new creation and shares with the parents their varying emotions.

Maternal and Neonatal Outcomes of Successful Kiellandʼs Rotational Forceps Delivery

OBJECTIVE To estimate the rates of early neonatal and maternal complications in a consecutive series of successful Kielland's rotational forceps deliveries. METHODS This was a retrospective cohort study of consecutive cases of successful rotational forceps deliveries performed in singleton pregnancies at 36 weeks of gestation or more in a tertiary referral center in Scotland, UK, from 2001 to 2008 (n=873). We also compared outcomes associated with successful rotational forceps deliveries in 2008 (n=150) with those of nonrotational forceps delivery (n=873), ventouse delivery (n=159), spontaneous vertex delivery (n=3,494), and emergency cesarean delivery (n=947). RESULTS There was one stillbirth associated with a rotational forceps delivery. This was diagnosed before application of forceps. After rotational forceps deliveries, 58 of 872 (6.7%) of live-born neonates were admitted to the neonatal unit. Twenty-seven of 872 (3.1%) neonates had one or more complications that could be attributable to traumatic delivery and seven neonates (0.8%) had a diagnosis of neonatal encephalopathy. When compared with alternative methods of delivery over a single year, neonatal admission rates after delivery by rotational forceps deliveries (5 of 150 [3.3%]) were not significantly different from spontaneous vertex delivery (128 of 3,494 [3.7%; P=1.00]) or ventouse delivery (6 of 159 [3.8%; P=1.00]) and lower than emergency cesarean delivery (106 of 947 [11.2%; P=.002). Postpartum hemorrhage rates after rotational forceps deliveries (8 of 150 [5.3%; P=.008]) were lower than those associated with emergency cesarean delivery (142 of 947 [15.0%; P=.008]). CONCLUSION Rates of short-term neonatal and maternal complications after successful rotational forceps deliveries are low. LEVEL OF EVIDENCE II.

Decision-making in operative vaginal delivery: when to intervene, where to deliver and which instrument to use? Qualitative analysis of expert clinical practice

ObjectiveTo identify the decision-making process involved in determining when to intervene, where to deliver and the optimal choice of instrument for operative vaginal deliveries in the second stage of labour. Study designA qualitative study using interviews and video recordings took place at two university teaching hospitals (St. Michael's Hospital Bristol and Ninewells Hospital, Dundee). Ten obstetricians and eight midwives were identified as experts in conducting or supporting operative vaginal deliveries. Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low cavity vacuum and mid-cavity rotational forceps deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and then compared for consistency of interpretation. The experts reviewed the coded interview and video data for respondent validation and clarification. The themes that emerged following the final coding were used to identify the decision-making process when planning and conducting an operative vaginal delivery. Key decision points were reported in selecting when and where to conduct an operative vaginal delivery and which instrument to use. ResultsThe final decision-making list highlights the various decision points to consider when performing an operative vaginal delivery. We identified clinical factors that experts take into consideration when selecting where the delivery should take place and the preferred choice of instrument. ConclusionThis detailed illustration of the decision-making process could aid trainees’ understanding of the approach to safe operative vaginal delivery, aiming to minimise morbidity.

Qualitative analysis by interviews and video recordings to establish the components of a skilled rotational forceps delivery

ObjectiveTo define the skills of a mid-cavity rotational forceps delivery to facilitate transfer of skills from expert obstetricians to trainee obstetricians. Study designQualitative interviews and video analysis carried out at maternity units of two university teaching hospitals (St. Michael's Hospital, Bristol, and Ninewells Hospital, Dundee). Ten obstetricians were identified as experts in conducting operative vaginal deliveries. Semi-structured interviews were carried out to identify key technical skills. The experts were also video recorded conducting mid-cavity rotational deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were individually coded by the three researchers and then compared for consistency of interpretation. The experts reviewed the data for respondent validation. The themes that emerged following the coding were used to formulate a taxonomy of skills. ResultsRotational forceps were preferred by eight experts and two experts preferred manual rotation followed by direct traction forceps. The final taxonomy included detailed technical skills for Kielland rotational forceps delivery and manual rotation followed by direct traction forceps delivery. ConclusionThis explicitly defined skills taxonomy could aid trainees’ understanding of the technique of rotational forceps delivery. This is an important potential contributor to safely reducing the rate of second-stage caesarean section.

Maternal and Neonatal Outcomes of Successful Kielland's Rotational Forceps Delivery

To estimate the rates of early neonatal and maternal complications in a consecutive series of successful Kielland's rotational forceps deliveries. This was a retrospective cohort study of consecutive cases of successful rotational forceps deliveries performed in singleton pregnancies at 36 weeks of gestation or more in a tertiary referral center in Scotland, UK, from 2001 to 2008 (n=873). We also compared outcomes associated with successful rotational forceps deliveries in 2008 (n=150) with those of nonrotational forceps delivery (n=873), ventouse delivery (n=159), spontaneous vertex delivery (n=3,494), and emergency cesarean delivery (n=947). There was one stillbirth associated with a rotational forceps delivery. This was diagnosed before application of forceps. After rotational forceps deliveries, 58 of 872 (6.7%) of live-born neonates were admitted to the neonatal unit. Twenty-seven of 872 (3.1%) neonates had one or more complications that could be attributable to traumatic delivery and seven neonates (0.8%) had a diagnosis of neonatal encephalopathy. When compared with alternative methods of delivery over a single year, neonatal admission rates after delivery by rotational forceps deliveries (5 of 150 [3.3%]) were not significantly different from spontaneous vertex delivery (128 of 3,494 [3.7%; P=1.00]) or ventouse delivery (6 of 159 [3.8%; P=1.00]) and lower than emergency cesarean delivery (106 of 947 [11.2%; P=.002). Postpartum hemorrhage rates after rotational forceps deliveries (8 of 150 [5.3%; P=.008]) were lower than those associated with emergency cesarean delivery (142 of 947 [15.0%; P=.008]). Rates of short-term neonatal and maternal complications after successful rotational forceps deliveries are low. II.

Maternal and neonatal outcomes following Kielland's rotational forceps delivery

BackgroundThere has been a decline in the use of Kielland's rotational forceps for malpositions, associated with reports that their use results in increased complications. However, most of these studies date...

Outcomes of operative delivery in the second stage of labour

IntroductionAttention has focused recently on improving trainee's skills at operative vaginal delivery to reduce the number of Caesarean sections in the second stage of labour. There are limited data available...