Re: Ghaem-Maghami S, Brockbank E, Bridges J. 2006. Survey of surgical experience during training in obstetrics and gynaecology in the UK. Journal of Obstetrics and Gynaecology 26(4):297 – 301

Dear Sir,

We read with interest the recent study by Ghaem-Maghami et al. (2006) on the surgical confidence reported by trainees in obstetrics and gynaecology in UK. In some ways, we were not surprised to learn that up to half of the senior trainees were not confident when asked to do a caesarean hysterectomy or repair a ruptured uterus unsupervised. These occur relatively infrequently (incidence of peripartum hysterectomy being approximately 0.05% in the western world) and many newly appointed consultants would request senior help when confronted with the above procedures. We are impressed that as many as 15/103 responders (14.5%) are confident in doing internal iliac ligation, a procedure that is rarely practiced in current obstetrics and we wonder if this is really representative of the current state of training in obstetrics and gynaecology.

We would like to share our experience of a telephone survey conducted in 2004, of 102 registrar grade doctors (ranging from Year 1 to Year 5) in North Thames, with regard to their views on training in instrumental vaginal deliveries. Of those questioned, 31/102 (30%) were senior trainees of Year 4 and above. A total of 47.5% were UK graduates and 61% were post-MRCOG. Most trainees (72.8% and 76.3%, respectively) had done less than 20 directly supervised ventouse and forceps before being allowed to perform these procedures independently. There were more trainees who felt ‘not confident’ doing forceps compared with ventouse deliveries (11.9% vs 0%). There was more direct supervision and teaching by consultants in forceps compared with ventouse (30% vs 12%) deliveries; in fact, 70% of current registrars had been taught ventouse by their registrars. Thus, although the bulk of training in instrumental deliveries was conducted by registrars, there was more consultant input in forceps deliveries. Interestingly, registrars who had been taught by their consultants in either forceps or ventouse deliveries expressed that they feel better ‘trained’, compared with those who had been taught by their registrars.

A total of 89% of trainees thought themselves confident (Visual Analogue Score of more than 7/10) when doing ventouse but only 57.84% expressed confidence when performing forceps deliveries. Instrumental vaginal deliveries comprise up to 24% of all deliveries in the UK (Middle and MacFarlane 1995) and it is worrying that 11% of obstetric registrars in the North Thames region feel that they are inadequately trained in ventouse deliveries and nearly half did not feel confident when doing forceps. Calmanisation of training and the implementation of the European Time Directive have resulted in fewer opportunities available to acquire skill on labour wards. To prevent further decline in the use of the obstetric forceps, we should encourage rigorous, structured and possibly consultant-led training on forceps deliveries.