Grand Rounds: Protecting the perineum during operative vaginal delivery


Unless operative vaginal delivery can be made at least as safe as cesarean delivery, it will be difficult to justify its continued existence. Proper technique is paramount.

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Operative vaginal delivery-which includes vaginal birth with the assistance of either forceps or vacuum devices-is one of the few remaining areas in obstetrics that may still be called an "art." But how long can it survive in an era of concerns about integrity of maternal tissues and short-and long-term maternal and fetal outcomes-a climate in which legal liability has contributed to ever-diminishing vaginal birth rates? Such concerns are amplified for operative (vs. nonoperative) vaginal delivery and threaten to eliminate the procedure from the armamentarium of newly trained obstetricians.

Compare trainees' experience with operative vaginal delivery to cesarean delivery. The Accreditation Council for Graduate Medical Education (ACGME) reports that in academic year 2005/2006, the national median for cesarean delivery cases per senior resident graduate over 4 years (either as primary operator or assistant) was 243 (ACGME Summary Report: Obstetrics; Residency Review Committee for Obstetrics and Gynecology, 2006). In contrast, the median 4-year experience for forceps was 11 cases and for vacuum extraction, 21. Most practitioners would agree that these numbers represent an inadequate level of training in operative vaginal delivery.

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