Re: Savage W, Francome C. 2007. British consultants' attitudes to caesareans. Journal of Obstetrics and Gynaecology 27:354 – 359

Dear Sir,

I read Savage and Francome's paper on the attitudes of British consultants to caesarean sections, which rated reduced skill of newly appointed consultants and non-consultant staff as a major reason for an increase in caesarean section rate. This is further supported by Spencer et al.'s (2006) editorial in the British Medical Journal.

As a year one specialist registrar in obstetrics and gynaecology in a maternity unit undertaking 4,200 deliveries annually, over the last 10 months, I have undertaken 75 emergency and elective caesareans. By comparison, I have undertaken nine second-stage trial of instrumental deliveries in theatre (decision for trial in theatre having been taken by myself). Of these, five were performed successfully by myself out of working hours, without supervision. One was supervised by a consultant, with a successful assisted vaginal delivery undertaken by myself. Three resulted in caesarean sections, two of which had unsuccessful Kielland's forceps rotations, performed by the consultants on call. Following the application and use of Kielland's forceps, one patient required a crash caesarean section secondary to a resultant fetal bradycardia.

In total, I have observed two deliveries involving Kielland's forceps in the last year, during which I was asked to scrub, in the likelihood of proceeding to caesarean section; both did result in caesarean section deliveries.

Overall, I have no doubt that my operative skills in regards to caesarean section have improved, but my confidence in performing trial of instrumentals and the use of Kielland's forceps has not. A quick survey among my peers has revealed similar experiences.

Furthermore, a discussion among senior staff earlier this year reflected upon the success of second-stage trial of instrumental deliveries within the department. This led to speculation that success may be related to gender of the doctor conducting the trial, leading to a debate as to whether the success of instrumental deliveries is greater influenced by strength or skill. With more female trainees pursuing a career in obstetrics and gynaecology, the question remains as to whether gender is a significant influencing factor on the success rate of instrumental deliveries.

As the number of working hours fall, and the number of doctors participating in maternity rotas increases, the need for supervised hands-on training has never been more important to ensure that the future generation of obstetricians are competent at assisted vaginal deliveries. Potentially, this could include pro-active consultant supervision of second-stage trial of instrumental deliveries in theatre, particularly during working hours.