An international assessment of trainee experience, confidence, and comfort in operative vaginal delivery

Training and expertise in undertaking assisted vaginal delivery (AVD): a mixed methods systematic review of practitioners views and experiences

BACKGROUND

During childbirth, complications may arise which necessitate an expedited delivery of the fetus. One option is instrumental assistance (forceps or a vacuum-cup), which, if used with skill and sensitivity, can improve maternal/neonatal outcomes. This review aimed to understand the core competencies and expertise required for skilled use in AVD in conjunction with reviewing potential barriers and facilitators to gaining competency and expertise, from the point of view of maternity care practitioners, funders and policy makers.

METHODS

A mixed methods systematic review was undertaken in five databases. Inclusion criteria were primary studies reporting views, opinions, perspectives and experiences of the target group in relation to the expertise, training, behaviours and competencies required for optimal AVD, barriers and facilitators to achieving practitioner competencies, and to the implementation of appropriate training. Quality appraisal was carried out on included studies. A mixed-methods convergent synthesis was carried out, and the findings were subjected to GRADE-CERQual assessment of confidence.

RESULTS

31 papers, reporting on 27 studies and published 1985-2020 were included. Studies included qualitative designs (3), mixed methods (3), and quantitative surveys (21). The majority (23) were from high-income countries, two from upper-middle income countries, one from a lower-income country: one survey included 111 low-middle countries. Confidence in the 10 statements of findings was mostly low, with one exception (moderate confidence). The review found that AVD competency comprises of inter-related skill sets including non-technical skills (e.g. behaviours), general clinical skills; and specific technical skills associated with particular instrument use. We found that practitioners needed and welcomed additional specific training, where a combination of teaching methods were used, to gain skills and confidence in this field. Clinical mentorship, and observing others confidently using the full range of instruments, was also required, and valued, to develop competency and expertise in AVD. However, concerns regarding poor outcomes and litigation were also raised.

CONCLUSION

Access to specific AVD training, using a combination of teaching methods. Complements, but does not replace, close clinical mentorship from experts who are positive about AVD, and opportunities to practice emerging AVD skills with supportive supervision. Further research is required to ascertain effective modalities for wider training, education, and supportive supervision for optimal AVD use.

Factors affecting confidence and competence of doctors in performing operative vaginal births: A qualitative study

OBJECTIVES

Operative vaginal birth (OVB) is an important skill for obstetricians. It is the most common emergency intervention in obstetrics and requires a high degree of skill. While there is a lot of data available on technical and non-technical factors affecting the outcome of OVBs little work has been done to investigate the factors that make obstetricians feel confident and competent when performing such a procedure. The objective of this study was therefore to identify the common factors that affect confidence and competence of obstetricians in operative vaginal births (OVB). Our hypothesis was that a qualitative research method would provide a rich approach where themes would be developed that the participants themselves identify as important.

STUDY DESIGN

Qualitative research within two University Hospitals and one District Hospital in Ireland. Participants interviewed ranged from first year trainees to consultant obstetricians. Interviews using open ended questions. Interviews were recorded on audio and later transcribed. Thematic analysis was performed until saturation.

RESULTS

35 obstetricians were interviewed. The median number of years of experience was 5 years (range 3-20 years). The median number of OVB was 200 (range 20-1000+). Vacuum was the preferred choice amongst junior trainees. Preference shifted to forceps with increasing clinical experience. Seven clear themes emerged. Three themes were common to all participants: firstly, that all clinicians reported respect for the primiparous OVB in anticipation of possible complications, secondly the wish for senior midwifery support and finally the importance of clinical experience and exposure. Four themes were common to trainees only. Female clinicians in training reported significant self-doubt in their ability to perform an OVB and had concerns about causing harm. Clinicians in training wished to be trained by consultants during their first year on the labour ward. Experience was important. The final theme was a wish for more training in forceps OVB by clinicians in training.

CONCLUSION

This qualitative study identified factors that can be used to design education and training in OVB in order to support trainees and ultimately improve care for the woman and baby.

Simulation for intrapartum care: from training to novel device innovation

Improving maternal and perinatal care is a global priority. Simulation training and novel applications of simulation for intrapartum care may help to reduce preventable deaths worldwide. Evaluation studies have published details of the effectiveness of simulation training for obstetric emergencies, exploring clinical and non-clinical factors as well as the impact on patient outcomes (both maternal and neonatal). This review summarized the many uses of simulation in obstetric emergencies from training to assessment. It also described the adaption of training in low-resource settings and the evidence behind the equipment recommended to support simulation training. The review also discussed novel applications for simulation such as its use in the development of a new device for assisted vaginal birth and its potential role in Cesarean section training. This study analyzed the financial implications of simulation training and how this may impact the delivery of such training packages, considering that simulation should be developed and utilized as a key tool in the development of safe intrapartum care in both emergency and non-emergency settings, in innovation and product development.

Women's, partners' and healthcare providers' views and experiences of assisted vaginal birth: a systematic mixed methods review

BACKGROUND

When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use.

METHODS

Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix.

RESULTS

Forty-two studies (published 1985-2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies.

CONCLUSIONS

Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.