Many emergency caesareans could be prevented by the attendance of a more skilled obstetrician, say senior doctors in this week’s British Medical Journal.

They call for better training in instrumental vaginal delivery (use of forceps or ventouse) for obstetric trainees to help reduce rates.

A recent UK study found that decisions made by senior (consultant) obstetric staff are important in determining whether a second stage caesarean section is the best method of delivery for women with delay in advanced labour. It found that a consultant obstetrician who performed a vaginal assessment was more likely to reverse a decision made by an obstetric trainee for a caesarean and proceed to a safely conducted instrumental delivery.

The authors warn that, without increases in junior doctors’ experience and recruitment into the specialty, the problems with second stage caesareans will rise.

According to the Royal College of Obstetricians and Gynaecologists audit figures, about 35% of caesareans for singleton pregnancies are performed because of failure to progress in labour, of which a quarter occur at full cervical dilatation. In 55% of these cases no attempt was made to achieve a vaginal birth with either forceps or ventouse. In those births where instrumental delivery was attempted, the audit noted a “failed” rate of 35% for ventouse and 2% for forceps.

Breech and twin deliveries can also lead to second stage caesareans. In the absence of an experienced and skilful obstetrician to perform assisted vaginal breech delivery, women are advised to undergo an emergency caesarean.

For twin deliveries, currently about 10% of second twins are delivered by caesarean section after the first has been delivered vaginally: 10 years ago, the rate was 5%. As many as two thirds of these caesareans are preventable, say the authors.

Despite problems relating to the inexperience of obstetric trainees, the United Kingdom is making great strides in terms of structured training, assessment of competencies, and consultant delivered intrapartum care, they write. Nevertheless, it is essential to recognise the need for obstetricians to maintain and develop their skills if women are to be offered safe alternatives to caesarean section when complications arise in labour.

http://www.bmj.com