Non-technical skills for obstetricians conducting forceps and vacuum deliveries: qualitative analysis by interviews and video recordings

Objective

Non-technical skills are cognitive and social skills required in an operational task. These skills have been identified and taught in the surgical domain but are of particular relevance to obstetrics where the patient is awake, the partner is present and the clinical circumstances are acute and often stressful. The aim of this study was to define the non-technical skills of an operative vaginal delivery (forceps or vacuum) to facilitate transfer of skills from expert obstetricians to trainee obstetricians.

Study design

Qualitative study using interviews and video recordings. The study was conducted at two university teaching hospitals (St. Michael's Hospital, Bristol and Ninewells Hospital, Dundee). Participants included 10 obstetricians and eight midwives identified as experts in conducting or supporting operative vaginal deliveries. Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting forceps and vacuum deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by the three researchers and then compared for consistency of interpretation. The experts reviewed the coded data for respondent validation and clarification. The themes that emerged were used to identify the non-technical skills required for conducting an operative vaginal delivery.

Results

The final skills list was classified into seven main categories. Four categories (situational awareness, decision making, task management, and team work and communication) were similar to the categories identified in surgery. Three further categories unique to obstetrics were also identified (professional relationship with the woman, maintaining professional behaviour and cross-monitoring of performance).

Conclusion

This explicitly defined skills taxonomy could aid trainees’ understanding of the non-technical skills to be considered when conducting an operative vaginal delivery and potentially reduce morbidity and improve the experience of delivery for the mother.     

Decision-making in operative vaginal delivery: when to intervene,where to deliver and which instrument to use? Qualitative analysis of expert clinical practice

Objective

To identify the decision-making process involved in determining when to intervene, where to deliver and the optimal choice of instrument for operative vaginal deliveries in the second stage of labour.

Study design

A qualitative study using interviews and video recordings took place at two university teaching hospitals (St. Michael's Hospital Bristol and Ninewells Hospital, Dundee). Ten obstetricians and eight midwives were identified as experts in conducting or supporting operative vaginal deliveries. Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video recorded conducting low cavity vacuum and mid-cavity rotational forceps deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were independently coded by three researchers and then compared for consistency of interpretation. The experts reviewed the coded interview and video data for respondent validation and clarification. The themes that emerged following the final coding were used to identify the decision-making process when planning and conducting an operative vaginal delivery. Key decision points were reported in selecting when and where to conduct an operative vaginal delivery and which instrument to use.

Results

The final decision-making list highlights the various decision points to consider when performing an operative vaginal delivery. We identified clinical factors that experts take into consideration when selecting where the delivery should take place and the preferred choice of instrument.

Conclusion

This detailed illustration of the decision-making process could aid trainees’ understanding of the approach to safe operative vaginal delivery, aiming to minimise morbidity.     

Qualitative analysis by interviews and video recordings to establish the components of a skilled rotational forceps delivery

Objective

To define the skills of a mid-cavity rotational forceps delivery to facilitate transfer of skills from expert obstetricians to trainee obstetricians.

Study design

Qualitative interviews and video analysis carried out at maternity units of two university teaching hospitals (St. Michael's Hospital, Bristol, and Ninewells Hospital, Dundee). Ten obstetricians were identified as experts in conducting operative vaginal deliveries. Semi-structured interviews were carried out to identify key technical skills. The experts were also video recorded conducting mid-cavity rotational deliveries in a simulation setting. The interviews and video recordings were transcribed verbatim and analysed using thematic coding. The anonymised data were individually coded by the three researchers and then compared for consistency of interpretation. The experts reviewed the data for respondent validation. The themes that emerged following the coding were used to formulate a taxonomy of skills.

Results

Rotational forceps were preferred by eight experts and two experts preferred manual rotation followed by direct traction forceps. The final taxonomy included detailed technical skills for Kielland rotational forceps delivery and manual rotation followed by direct traction forceps delivery.

Conclusion

This explicitly defined skills taxonomy could aid trainees’ understanding of the technique of rotational forceps delivery. This is an important potential contributor to safely reducing the rate of second-stage caesarean section.     

Kjelland's forceps in the new millennium. Maternal and neonatal outcomes of attempted rotational forceps delivery

Background:  The use of Kjelland's forceps is now uncommon, and published maternal and neonatal outcome data are from deliveries conducted more than a decade ago. The role of Kjelland's rotational delivery in the 'modern era' of high caesarean section rates is unclear.
Aims:  To compare the results of attempted Kjelland's forceps rotational delivery with other methods of instrumental delivery in a tertiary hospital.
Methods:  Retrospective review of all instrumental deliveries for singleton pregnancies 34 or more weeks gestation in a four-year birth cohort, with reference to adverse maternal and neonatal outcomes.
Results:  The outcomes of 1067 attempted instrumental deliveries were analysed. Kjelland's forceps were successful in 95% of attempts. Kjelland's forceps deliveries had a rate of adverse maternal outcomes indistinguishable from non-rotational ventouse, and lower than all other forms of instrumental delivery. Kjelland's forceps also had a lower rate of adverse neonatal outcomes than all other forms of instrumental delivery.
Conclusions:  Prudent use of Kjelland's forceps by experienced operators is associated with a very low rate of adverse maternal and neonatal outcomes. Training in this important obstetric skill should be reconsidered urgently, before it is lost forever.     

Operative vaginal delivery and the use of episiotomy--a survey of practice in the United Kingdom and Ireland

OBJECTIVE: To establish the views and current practice of obstetricians with regard to operative vaginal delivery and the use of episiotomy. STUDY DESIGN: A national survey of consultant obstetricians and specialist registrars practising in the United Kingdom and Ireland registered with the Royal College of Obstetricians and Gynaecologists (RCOG), London. A postal questionnaire was sent to all obstetricians with two subsequent reminders to non-responders. The choice of procedure for specific circumstances, instrument preference, use of episiotomy and views on the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery were explored. RESULTS: The response rate was 80.4%. Instrument preference varied according to the fetal position and station and the grade of operator. Vacuum and forceps were both used for mid-cavity non-rotational deliveries (64% and 56% reported frequent use respectively). Rotational vacuum was preferred for a mid-cavity mal-position (69%) followed by equal numbers using rotational forceps or manual rotation and forceps (34% and 36%, respectively). Inexperienced operators were more likely to proceed directly to caesarean section (35%). A restrictive approach to use of episiotomy was preferred for vacuum delivery (72%) and a routine approach for forceps (73%). Obstetricians varied greatly in their perception of the relationship between episiotomy use and anal sphincter tears at operative vaginal delivery. CONCLUSION: There is wide variation in the use of episiotomy at operative vaginal delivery with uncertainty about its role in preventing anal sphincter tears. A randomised controlled trial would address this important aspect of obstetric care.     

Objective assessment of surgical competence in gynaecological laparoscopy: development and validation of a procedure-specific rating scale

Objective  The purpose of this study was to develop a global- and a procedure-specific rating scale based on a well-validated generic model (objective structured assessment of technical skills) for assessment of technical skills in laparoscopic gynaecology. Furthermore, we aimed to investigate the construct validity and the interrater agreement (IRA) of the rating scale. We investigated both the gamma coefficient (Kendall's rank correlation), which is a measure of the strength of dependence between observations, and the kappa value for each of the ten individual items included in the rating scale.
Design  Prospective cohort, observer-blinded study.
Setting  Departments of Obstetrics and Gynaecology in Zealand, Denmark.
Population  Twenty one gynaecologists or gynaecological trainees.
Material and methods  Twenty-one video recordings of right side laparoscopic salpingectomies were collected prospectively, eight from novices (defined as <10 procedures), seven from intermediate experienced (20–50 procedures) and six from experts (>200 procedures). All operations were performed by the same operative principles and using a standardised technique. The recordings were analysed by two independent, blinded observers.
Main outcome measures  Construct validity of the rating scale based on operative performance (median of total score) and interrater reliability.
Results  There were significant differences between the three groups: median score of novices 24.00 versus intermediate 29.50 versus expert 39.50, P < 0.003) The IRA was 0.83 overall. The gamma correlation coefficient was 0.91. The kappa values varied from 0.510–0.933 for each of the individual items of the rating scale.
Conclusions  The procedure-specific rating scale for laparoscopic salpingectomy is a valid and reliable tool for assessment of technical skills in gynaecological laparoscopy.     

Vacuum-assisted delivery: a review.

In 1992, the number of vacuum deliveries overtook the number of forceps deliveries performed in the USA. Most clinical experiences report that the vacuum is safe for both the fetus and the mother when used properly. Correct cup placement on the fetal head and knowing when to abandon the procedure, appear to be key components to conducting a safe and successful vacuum delivery. However, the focus and training that has been afforded forceps deliveries in the past has not been given to the vacuum, because of its perceived 'ease of use'. This apparent lack of understanding has led to increasing numbers of complications associated with its use. In addition, because forceps are being taught less in training programs, fewer and fewer physicians are being trained in the essential skills of operative vaginal delivery. This review is intended to emphasize the correct techniques and skills of vacuum-assisted vaginal delivery in an attempt to increase the success and decrease the complications associated with its use.     

Changed pattern in the use of episiotomy in Sweden

Objective To study changes in the use of episiotomy since 1989, controlling for variables such as severe tears, epidural anaesthesia, duration of the second stage of labour, instrumental deliveries, birthweight and maternal position at delivery.
Design Retrospective study. Data were obtained from original birth records and questionnaires.
Setting Huddinge University Hospital and all labour wards (   n = 62  ) in Sweden.
Population 10,661 women who were delivered vaginally (4575 nulliparae, 6086 multiparae) between 1992 and 1994, and 3366 nulliparae delivered in all Swedish hospitals during the month of March 1995.
Main outcome measures Episiotomy rates, severe tears and instrumental deliveries.
Results The rate of episiotomy was 1 % and of severe tears 0.6% among multiparae delivered vaginally (including instrumental deliveries) at Huddinge University Hospital between 1992 and 1994. The rate of episiotomy was 6.6% and of severe tears 2.3% among nulliparae. Vacuum extraction and epidural anaesthesia were more commonly associated with episiotomy. Factors significantly associated with severe tears were infant birthweight ≥ 4000 g, vacuum extraction and episiotomy. In all Swedish labour wards in 1995 the mean incidence of episiotomy in nulliparae was 24.5%, a significant decrease from 33.7% in 1989. Wide variations occurred between hospitals (4%-50%).
Conclusion The use of episiotomy was much reduced at Huddinge University Hospital, with a consistently low rate of severe tears. This supports the growing evidence for individualised and restrictive use of episiotomy at childbirth.     

Faecal incontinence after childbirth

Objective To measure the prevalence and severity of postpartum faecal incontinence, especially new incontinence, and to identify obstetric risk factors.
Design A cohort study with information on symptoms collected in home-based interviews and obstetric data from hospital casenotes.
Setting Deliveries from a maternity hospital in Birmingham.
Participants Nine hundred and six women interviewed a mean of 10 months after delivery.
Main outcome measures New faecal incontinence starting after the birth, including frank incontinence, soiling and urgency.
Results Thirty-six women (4%) developed new faecal incontinence after the index birth, 22 of whom had unresolved symptoms. Twenty-seven had symptoms several times a week, yet only five consulted a doctor. Among vaginal deliveries, forceps and vacuum extraction were the only independent risk factors: 12 (33%) of those with new incontinence had an instrumental delivery compared with 114 (14%) of the 847 women who had never had faecal incontinence. Six of those with incontinence had an emergency caesarean section but none became incontinent after elective sections.
Conclusions Faecal incontinence as an immediate consequence of childbirth is more common than previously realised, and medical attention is rarely sought. Forceps and vacuum extraction deliveries are risk factors, with no protection demonstrated from emergency caesarean section. Identification and treatment is a priority.     

Operative vaginal delivery: clinical appraisal of a new vacuum extraction device

The efficacy of a new vacuum extraction device, the Kiwi OmniCup, and its effects on mothers and infants were tested in a study of 18 non-rotational and 32 rotational vacuum assisted deliveries. Forty-nine (98%) of the extractions resulted in successful vaginal births. Autorotation of the fetal head when the occiput was transverse or posterior was achieved in 31 (97%) of the 32 vacuum procedures. The high success rates recorded for both vaginal delivery and autorotation of the fetal head were largely attributable to the fact that flexing cup applications were achieved in 90 % of the vacuum attempts. There were no cases of serious maternal trauma or clinically significant neonatal injuries. Two infants had cephalohaematomas and one infant developed a small subgaleal haemorrhage following a difficult delivery, which resolved rapidly without complications. It was concluded that the Kiwi OmniCup is an efficient and safe vacuum device for assisted vaginal delivery, provided it is used correctly and appropriately.     

Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery

Objective  To determine the risk factors for anal sphincter injuries during operative vaginal delivery.
Setting and design  A population-based observational study.
Population  All 21 254 women delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995.
Methods  Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis.
Main outcome measures  Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc.
Results  Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09–0.13) and forceps delivery (OR 0.08, 95% CI 0.07–0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries.
Conclusions  Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.     

A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique

Objective To evaluate the outcome of caesarean delivery performed by assistant medical officers and specialists in obstetrics and gynaecology with particular attention to post-operative complications.
Design We performed a nonrandomised analysis of 2071 consecutive caesarean deliveries at Maputo Central Hospital. Of these, 958 (46.3%) were performed by assistant medical officers (medical assistants trained for surgery) and the rest (53.7%) by specialists in obstetrics and gynaecology. The age and parity distributions of women in the two groups were almost identical.
Setting University Hospital in Maputo, covering all emergency obstetrics with about 48,000 deliveries per year.
Population Two thousand and seventy-one consecutive caesarean deliveries.
Main outcome measures Post-operative complications and the duration of post-operative hospital stay.
Results There were no differences in the indications for caesarean delivery. The surgical interventions associated with caesarean delivery did not differ in the two groups. The only significant difference was in the group of superficial wound separation due to haematoma, which was slightly more common (0.35% vs 0.05%) in the group operated on by assistant medical officers (Odds Ratio 2.2; 95% Confidence Interval 1.3–3.9)
Conclusion Training selected medical assistants to perform caesarean delivery, even on women in poor general condition, is justified in settings in which doctors are scarce.     

阴道手术产

阴道手术产是指助产者运用产钳或胎头吸引器使胎儿经阴道分娩,由于产科医生经验和能力的缺乏而使经阴道助产手术分娩的数量下降。文章就阴道手术产的指征、手术技巧、并发症以及手术方式的选择等进行讨论。     

Subgaleal hemorrhage with dural tear and parietal-lobe herniation in association with a vacuum extraction.

Use of the vacuum for operative vaginal deliveries has become more favorable with fewer obstetricians and family practitioners trained in the use of forceps. When compared with forcep-assisted deliveries, the vacuum has been associated with a higher incidence of subgaleal hemorrhage (SGH), cephalhematomas, skull and clavicular fractures, Erb's Palsy, intracranial hemorrhage and need for ICN admission. We report the case of an infant who developed a large SGH with midline dural tear and herniation of the medial aspect of the parietal lobes bilaterally in association with a vacuum extraction (VE) delivery. Counseling of families prior to instrumented delivery as to the potential complications, adherence to recommendations for abandoning operative vaginal delivery in favor of a cesarean section and close observation of those infants delivered by VE is warranted.     

Instrumental extraction in 2002 in the "AURORE" hospital network: incidence and serious neonatal complications

OBJECTIVES: The purpose of this study was to evaluate the incidence of forceps and vacuum application and the incidence of its related neonatal complications. This study was performed in a network of 37 maternity hospitals. PATIENTS AND METHOD: A postal questionnaire was sent to 156 obstetricians between February and March 2003. RESULTS: Response rate was 78%. In 2002 the operative vaginal delivery rate was 11.2% of all live births. Forceps are the primary instruments (6.3%) whereas vacuum delivery rate was 4.9%. One obstetrician never uses forceps while 38 (31%) never use vacuum. Only 29 (24%) report using both instruments frequently. During 2002 no neonatal death related to an operative vaginal delivery was reported while 145 neonatal complications were (3.2%). Major complications were one depressed skull fracture (1/4589) and 14 extensive caput succedaneum (14/4589). Minor complications were cutaneous lesions (124/4589) and facial palsy (6/4589). Vacuum delivery was associated with a significantly higher extensive caput succedaneum rate (P = 0.018) while the only depressed skull fracture observed was related to forceps use. Forceps delivery was associated with a significantly higher cutaneous lesions rate (P < 0.001). DISCUSSION AND CONCLUSIONS: This study showed that, in 2002, operative vaginal deliveries still represent a significant amount of vaginal deliveries, a majority of obstetricians do not use both instrument and neonatal associated complications are frequent (3.2%) but rarely severe. Therefore, we believe that every method that allows a safe teaching of operative delivery should be promoted.     

Risk factors for third degree perineal ruptures during delivery

Objective To determine risk factors for the occurrence of third degree perineal tears during vaginal delivery.
Design A population-based observational study.
Population All 284,783 vaginal deliveries in 1994 and 1995 recorded in the Dutch National Obstetric Database were included in the study.
Methods Third degree perineal rupture was defined as any rupture involving the anal sphincter muscles. Logistic regression analysis was used to assess risk factors.
Main outcome measures An overall rate of third degree perineal ruptures of 1.94% was found. High fetal birthweight, long duration of the second stage of delivery and primiparity were associated with an elevated risk of anal sphincter damage. Mediolateral episiotomy appeared to protect strongly against damage to the anal sphincter complex during delivery (OR: 0.21, 95% CI: 0.20–0.23). All types of assisted vaginal delivery were associated with third degree perineal ruptures, with forceps delivery (OR: 3.33, 95%-CI: 2.97–3.74) carrying the largest risk of all assisted vaginal deliveries. Use of forceps combined with other types of assisted vaginal delivery appeared to increase the risk even further.
Conclusions Mediolateral episiotomy protects strongly against the occurrence of third degree perineal ruptures and may thus serve as a primary method of prevention of faecal incontinence. Forceps delivery is a stronger risk factor for third degree perineal tears than vacuum extraction. If the obstetric situation permits use of either instrument, the vacuum extractor should be the instrument of choice with respect to the prevention of faecal incontinence.     

Clinical evaluation of a "hand pump" vacuum delivery device

OBJECTIVE: To evaluate the clinical performance of a hand-held vacuum delivery system. METHODS: Between December 1999 and September 2000, a prospective audit was undertaken of all vacuum deliveries performed at Derby City General Hospital. RESULTS: In this period, 3296 deliveries occurred, of which 317 (9.6%) were by vacuum. Of these, data were collected on 300 (94.6%), 78 deliveries with the hand-held vacuum and 222 with standard vacuum. There were no differences in the demographic profiles, indication, gestational age at delivery, or birth weights between the two groups (P >.05 in all instances). In all types of delivery, nonrotational and rotational, the hand-held vacuum performed comparably to its contemporaries with no increase in delivery "failures" being noted. There were no differences in the extent or frequency of maternal injuries between the instruments, and other than transient scalp abrasions, there were no significant fetal injuries. CONCLUSION: The hand-held vacuum delivery system is a functionally effective addition to the practitioners' "armory," providing an alternative to the standard metal and silastic cups.     

Impact of Provider Payment Structure on Obstetric Interventions and Outcomes: A Difference-in-Differences Analysis

ObjectiveTraditionally, Canadian physicians provide care on a fee-for-service (FFS) basis; however, this model has been criticized as it incentivizes quantity of care over quality of care. Consequently, all Canadian provinces and territories have implemented some form of alternative payment plan. Evaluation of the impact of these policy changes, however, has typically focused on family physicians as opposed to specialists.MethodsOn January 1, 2004, obstetricians at the Medicine Hat Regional Hospital (MHRH) transitioned from FFS to salary. A difference-in-differences analysis was used to examine the impact of changes in obstetrician payment structure on the use of obstetric interventions and neonatal outcomes controlling for temporal trends at MHRH (intervention group) and the Chinook Regional Hospital (CRH; comparison group) from 2002 to 2005.ResultsBetween the pre-intervention period (2002-2003) and the post-intervention period (2004-2005), the rate of cesarean delivery increased significantly at both sites. Following adjustment for time of day, day of week, and antepartum risk score, the difference-in-difference estimator demonstrated a 5.8% (95% CI 1.5–10.0) increase in cesarean deliveries performed by obstetricians at MHRH compared with cesarean deliveries done at CRH after accounting for baseline differences and temporal trends. No significant differences were observed for family physicians. No significant differences were observed for other obstetric interventions or neonatal outcomes.ConclusionUnder an FFS model, obstetricians are incentivized to cesarean delivery due to the increased reimbursement rate; however, the increase in cesarean deliveries at MHRH following the transition to a salary model was unexpected. This finding suggests that, in Canada, financial incentives are not a factor that explains the increasing rate of cesarean delivery.     

Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review

Objectives  To assess if mode of delivery is associated with increased symptoms of anal incontinence following childbirth.
Design  Systematic review of all relevant studies in English.
Data sources  Medline, Embase, Cochrane Library, bibliographies of retrieved primary articles and consultation with experts.
Study selection and data extraction  Data were extracted on study characteristics, quality and results. Exposure to risk factors was compared between women with and without anal incontinence. Categorical data in 2 × 2 contingency tables were used to generate odds ratios.
Results  Eighteen studies met the inclusion criteria with 12 237 participants. Women having any type of vaginal delivery compared with a caesarean section have an increased risk of developing symptoms of solid, liquid or flatus anal incontinence. The risk varies with the mode of delivery ranging from a doubled risk with a forceps delivery (OR 2.01, 95% CI 1.47–2.74, P < 0.0001) to a third increased risk for a spontaneous vaginal delivery (OR 1.32, 95% CI 1.04–1.68, P = 0.02). Instrumental deliveries also resulted in more symptoms of anal incontinence when compared with spontaneous vaginal delivery (OR 1.47, 95% CI 1.22–1.78). This was statistically significant for forceps deliveries alone (OR 1.5, 95% CI 1.19–1.89, P = 0.0006) but not for ventouse deliveries (OR 1.31, 95% CI 0.97–1.77, P = 0.08). When symptoms of solid and liquid anal incontinence alone were assessed, these trends persisted but were no longer statistically significant.
Conclusion  Symptoms of anal incontinence in the first year postpartum are associated with mode of delivery.     

External cephalic version at term: a survey of consultant obstetric practice in the United Kingdom and Republic of Ireland

Objective To undertake a survey of external cephalic version (ECV) in the United Kingdom and Republic of Ireland.
Design In June 1995 every consultant obstetrician and gynaecologist in the United Kingdom and Republic of Ireland was sent a postal questionnaire which asked whether ECV was routinely performed for breech presentation after 37 weeks of gestation, assuming no contraindications. If consultants did not perform ECV, a supplementary question enquired whether they referred patients to a colleague who would perform ECV. The questionnaires were colour coded for country and dispatched from the Postgraduate Education Department of the Royal College of Obstetricians and Gynaecologists (RCOG).
Results Overall, 78% of questionnaires were returned. The percentage of consultants routinely practising ECV in each country was as follows: Northern Ireland 82%; Scotland 64%; Republic of Ireland 64%; England 43%; and Wales 41%. When these figures were compared with the latest RCOG Annual Statistical Returns for breech delivery and caesarean section for breech delivery, there was an inverse correlation between the percentage of obstetricians performing ECV in any one country and the incidence of breech delivery ( P < 0.001). There was a similar inverse correlation for the percentage of obstetricians performing ECV and the caesarean section rate for breech delivery ( P < 0.001).
Conclusion Although postal survey results are not necessarily an accurate reflection of what happens in clinical practice, these data are supported by evidence from the Cochrane Database of Systematic Reviews indicating that ECV after 37 weeks reduces the incidence of both breech delivery and caesarean section for breech delivery.