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    Clinician to Clinician: Bringing operative vaginal delivery into the 21st century

     

    Dr. Perone is a clinical professor in the Department of Obstetrics, Gynecology & Reproductive Sciences at the University of Texas Medical School at Houston. He reports holding a patent for an electronically controlled axis-traction handle and 2 related patents.

     

     

     

    Operative vaginal delivery (OVD) still plays a valuable role in obstetrics, despite its continuing decline. Many factors account for such a decline, including, in particular, doctors’ fear of litigation and reduced competency. Modern technology may preserve the use of forceps and vacuum extractor before it becomes a lost art.

    The rate of OVDs has been declining in most countries since the mid-1970s. In the United States, it has gone from 28% in 1970 to 9.01% in 1990, with a further drop to 3.5% in 2011.1 The rate of forceps use has dropped from almost 30% in the late 1960s to less than 1% in 2005, where it has remained. Vacuum extraction (VE) was seldom used in the United States until the early 1980s, but subsequently became the most common method of OVD after a marked increase from 3.5% in 1989 to 6.2% in 1997. Since then the rate of VE has steadily declined to a low of 2.85% in 2011.2

    Reasons behind OVD loss of favor

    A number of factors account for the decline in the rate of OVD, however medico-legal concerns may play a major role. In the 2012 ACOG professional liability survey, 77.3% of respondents said that they had been sued at least once, with an average of 2.64 claims per ob/gyn.3 Plaintiff attorneys frequently blame forceps and VE for bad obstetrical outcomes, although it is widely believed that the indication for their use is probably a more important causative factor than the delivery itself.4 This is particularly so in the case of neonatal neurologic damage, similar to what has been observed in case of cesarean delivery,5 which, despite its increasing rate, has not caused a reduction in cerebral palsy. In fact, a recent systematic literature review and meta-analysis has shown an increased risk of this neurologic condition in association with emergency cesarean delivery, confirming the important causative role of antepartum risk factors.6

    The reduced use of OVD and increased use of cesarean delivery at many teaching institutions has reduced resident competency in OVD. This may set in motion a vicious cycle, wherein lack of expertise causes errors when using forceps or VE, leading to more lawsuits, which in turn further discourages OVD. The important questions facing our specialty today are whether we want to passively witness OVD become “a lost art”7 while the cesarean delivery rate continues to climb, or whether we should actively attempt to reverse the current trend and, if so, how.

    Why proficiency in OVD should be maintained

    OVD should not be allowed to become extinct. Proficiency in the use of forceps and VE should be maintained for the following reasons:

     Cesarean delivery is not a panacea for all obstetrical emergencies. In fact, OVD can save the day whenever a cesarean delivery is either relatively contraindicated by maternal conditions or, as it happens more often, preparation for it cannot be made in a timely fashion (only 65% of emergency primary cesarean deliveries are done within 30 minutes of the decision to operate).8

     Given current patient safety and health care cost concerns, the potential moderating impact of OVD is widely acknowledged.9-11 In my opinion, it is no accident that, while OVD rates have gradually decreased, the rate of cesarean delivery has increased by more than 50% since 1996, going from 21% to 32.8 % in 2011. And this upward trajectory appears likely to continue, with estimates of an overall cesarean rate of 56.2% by 2020, if the primary and secondary cesarean rates continue at the same pace as in recent years.12,13 Of course, it is difficult, if not impossible, to quantitate precisely the effect that more frequent use of OVD would have on these rates. But it is clear that even a small reduction in cesarean deliveries could have considerable economic benefits. In fact, for every 5% increase in the US cesarean delivery rate one can expect $750 million to $1.7 billion in additional healthcare costs.14

    Nicola Perone, MD, FACOG, FACS
    Dr. Perone is a clinical professor in the Department of Obstetrics, Gynecology & Reproductive Sciences at the University of Texas ...

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