Current Commentary

Obstetric Forceps A Species on the Brink of Extinction Gary A. Dildy,

MD,

Michael A. Belfort,

MD,

and Steven L. Clark,

Both resident training in the use of obstetric forceps and forceps deliveries are experiencing precipitous declines in the United States. Current minimum training requirements are insufficient to ensure competency in this skill. These trends bear striking similarities to observations regarding the decline and ultimate extinction of biologic species and portend the inevitable disappearance of this valuable skill from the obstetric armamentarium. Attempts by experienced teaching faculty to provide residents with experience in a few forceps deliveries are of little value and may do more harm than good. There would seem to be only two viable solutions to this dilemma: 1) abandon attempts to teach forceps and prepare residents for a realworld practice setting in which management of secondstage labor does not include the availability forceps delivery; or 2) prioritize the development of high-fidelity simulation models in which fetal head size and attitude and pelvic size and architecture can be continuously varied to allow residents to obtain sufficient experience to know both how and when to proceed with forceps delivery. We believe this latter approach is the sole alternative to inevitable extinction of this species. (Obstet Gynecol 2016;128:436–9) DOI: 10.1097/AOG.0000000000001557

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ife on earth is represented by repetitive cycles of evolution and extinction; it is estimated that more than 95% of species that have ever lived on earth are now extinct.1 As technology has advanced, reading See related editorial on page 425.

From the Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas. Corresponding author: Steven L. Clark, MD, 6651 Main Street, Suite F1096, Houston, TX 77030; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/16

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a sundial is a lost art, few individuals can navigate by the stars, and slide rules have become obsolete. In the realm of biology, populations headed for extinction first pass a critical threshold beyond which extinction becomes inevitable.2 Occasionally, extraordinary human efforts may delay such extinction.3 Recent research involving complex mathematical modeling suggests that a phase of “critical slowing down” may immediately precede the point of no return and in some cases may give warning of impending extinction.4 It seems clear to us that the use of obstetric forceps is approaching this tipping point. Unfortunately, in the case of forceps, there is no equivalent to the slide rule’s calculator—no replacement that fills and exceeds all the roles of the earlier technology. Many neonates formerly delivered with forceps can now be safely delivered with a vacuum or by cesarean delivery. However, there remain critical gaps; consider, for example, a prolonged deceleration at +2 station in a mother with poor pushing efforts in which vacuum may be ineffective and cesarean delivery too slow. In such circumstances, a clinician skilled in forceps delivery may be the best hope for avoiding fetal neurologic injury, yet clinicians with such forceps skills are rare, and forceps deliveries appear to be headed for inevitable extinction. A decade ago, only half of chief residents reported feeling competent to perform forceps deliveries in the United States, and things appear to have deteriorated significantly since that time.5 Figure 1 represents trends in operative vaginal delivery rates in the United States. Figure 2 represents vacuum and forceps procedures performed by U.S.-trained residents over the past decade; the median number of forceps deliveries in 4-year U.S. training programs totals five for the most recent year reported by the Accreditation Council for Graduate Medical Education.6 In our opinion, five forceps deliveries are inadequate to provide even the most talented operator with the requisite technical skills to independently perform such deliveries safely, especially in an emergency. Of equal importance, such numbers cannot begin to equip a resident with the critical judgment skills

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Fig. 1. Operative vaginal delivery in the United States (1989–2013) as a percentage of all deliveries. Data from Refs. 22–26. Dildy. Extinction of Forceps. Obstet Gynecol 2016.

necessary to decide when or when not to perform such procedures. Current requirements for residency training in obstetrics specify that 15 total operative vaginal deliveries be performed; in most cases, these will consist exclusively or primarily of vacuum deliveries (Fig. 2). For most residents so trained, a carefully supervised forceps delivery (or five or even 15) becomes nothing more than a parlor trick rather than an effective training experience. One of us clearly recalls the expectation of 100 forceps deliveries in the postgraduate year-1 training year, after which we were, well, postgraduate year-2s and as such not close to being ready to perform unsupervised forceps deliveries. For better or for worse, the demise of purely elective forceps deliveries has permanently closed the door on such training experiences.

At Texas Children’s Hospital, a few of us are sometimes called on to assist with or to perform forceps deliveries when less experienced, younger obstetricians recognize that operative delivery is indicated, yet neither vacuum nor cesarean delivery is ideally suited to the clinical situation. We make every attempt to allow residents to participate in these deliveries, yet we wonder whether we are doing our residents a favor by providing this service as a crutch. What will they do by themselves at 3:00 AM in a private hospital? Will they realize that a second-stage fetal heart rate tracing that can be safely observed by an obstetrician who can deliver the neonate within minutes with forceps regardless of maternal pushing efforts may require emergent cesarean delivery when such skills are not available? Could our attempts to expose

Fig. 2. Median operative vaginal delivery procedures for U.S. residents completing residency programs between academic years 2002–2003 and 2014–2015 as reported by the Accreditation Council for Graduate Medical Education. Data from Refs. 27–40. OVD, operative vaginal delivery. Dildy. Extinction of Forceps. Obstet Gynecol 2016.

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residents to a few forceps deliveries be not only unhelpful, but harmful in the long run? So where do we go from here? There may be several options, but we feel certain that simply lamenting the demise of forceps and exposing residents to an occasional and dwindling experience with this instrument is not one of them. We echo the observation of the Institute of Medicine regarding the solution to similar issues in patient safety: “trying harder will not work.”7 New solutions are necessary. One idea might involve exposing a few select individuals to a higher volume of forceps deliveries during training. Because indications for such procedures arise unpredictably, residency work-hour restrictions make such a plan difficult, because a select few cannot be “on call” for all forceps deliveries. In addition, it seems unlikely that many enthusiastic young postgraduate year-1 physicians would volunteer to be on the Bteam with no interest in learning these skills. Perhaps more importantly (and in keeping with the metaphor driving this article), the reintroduction of a few individuals of a species raised in captivity into a declining wild population has proven generally ineffective in avoiding extinction, especially when the overall environment remains unfavorable.8 When such specialized training is possible, it may prove beneficial to the resident in question, and the patients they eventually care for, and is to be applauded. However, it is unlikely to be a long-term solution to the ongoing demise of this valuable skill. We see only two solutions with any realistic hope of implementation. The first is to simply recognize that, like the slide rule with which some older individuals are still adept, forceps deliveries are a relic of the past. Attempts to revive the species, given current training realities, are going to be unsuccessful and are potentially harmful. Those with the requisite skills should continue to use them but not fool themselves into thinking that residents can be adequately trained or that forceps deliveries will have any role in obstetrics beyond the next decade. Let forceps die with dignity. Do not resuscitate. The second solution is to develop a high-fidelity simulation model for forceps deliveries in which both the size and position of the fetal head, the size and shape of the maternal pelvis, and the volume of maternal soft tissue can be manipulated. Such a model would provide a life-like training experience with a wide variety of clinical scenarios in which both technical skill and judgment could be taught and practiced. One hundred such forceps deliveries in the postgraduate year-1 year may not be unrealistic. Because clinical indications for these procedures will always be limited, postgraduate retraining on this model might be required for privileging and recredentialing.

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Full-body simulator models and virtual reality approaches exist today that incorporate computerized systems and closely approximate human physiology. Such models are currently used in training for advanced trauma and life support, general surgery, anesthesiology, laparoscopy, ultrasonography, and fetal surgical procedures.9–16 Although initial work with computer modeling of forceps placement and trajectory of delivery is promising, and undoubtedly helps residents conceptualize the intended procedure, such work has not led to a useable model that approximates clinical experience.17–19 We find it difficult to believe that the technology involved in the development of such simulation is not possible and would not be orders of magnitude simpler than existing simulators utilized in other types of complex training, particularly for military applications.20 We feel confident that, if demanded and supported by the specialty, such a model could be developed in partnership with industry for training in operative vaginal delivery as well. New, innovating, resource-intensive approaches requiring a departure from traditional ways of thinking have brought other species back from the brink of extinction.3,21 We feel one last concerted effort at saving the obstetric forceps is worth a similar effort. REFERENCES 1. The Smithsonian Institution, Department of Paleobiology. Foundational concepts: extinction. Available at: http://paleobiology.si. edu/geotime/main/foundation_life4.html. Retrieved July 5, 2016. 2. With KA, King AW. Extinction thresholds for species in fractal landscapes. Conservation Biol 1999;13:314–26. 3. National Geographic Society. California condor. Available at: http://animals.nationalgeographic.com/animals/birds/californiacondor. Retrieved March 28, 2016. 4. Drake JM, Griffin BD. Early warning signals of extinction in deteriorating environments. Nature 2010;467:456–9. 5. Powell J, Gilo N, Foote M, Gil K, Lavin JP. Vacuum and forceps training in residency: experience and self-reported competency. J Perinatol 2007;27:343–6. 6. National resident data summary report. Available at: http://www. acgme.org/Portals/0/PDFs/220_National_Report_Program_ Version.pdf. Retrieved July 5, 2016. 7. Crossing the quality chasm. Washington, DC: Institute of Medicine; 2001. 8. Snyder NFR, Derrickson SR, Beissinger SR, Wiley JW, Smith TB, Toone WD, et al. Limitations of captive breeding in endangered species recovery. Conservation Biol 1996;10:338–48. 9. Cherry RA, Williams J, George J, Ali J. The effectiveness of a human patient simulator in the ATLS shock skills station. J Surg Res 2007;139:229–35. 10. Stefanidis D, Sevdalis N, Paige J, Zevin B, Aggarwal R, Grantcharov T, et al. Simulation in surgery: what’s needed next. Ann Surg 2015;261:846–53. 11. American Society of Anesthesiologists. Simulation education. Available at: https://www.asahq.org/education/simulation-education. Retrieved March 28, 2016.

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