operative vaginal deliveries!

[Miss Alyssa]

Do you know of, or have experience with, a residency program that provides training on forceps and vacuum delivers, vaginal breech delivery and VBAC?

On the website for Maimonides Medical Center it says that after grad, residents are 'qualified' to do (among other things) VBAC, vaginal breech, forceps and vacuum delivery.

Washington Hospital also gives training in operative vaginal and breech delivery.

As I'm going through different programs these are the only one I've seen mention breech, forceps, or vacuum delivery. Of course you can't put everything on your website. So does anyone have knowledge of other programs where you'd get significant experience in these ares?

Is it something that most programs do offer but don't advertise?

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[wannabeOBGYN]

Most places I went to for interviews said they "teach breech" during breech c-sections because it's the same method. I don't know if that's necessarily true as I haven't done both to compare. Reading Hospital does a lot of breech deliveries because of the Amish population. In regards to operative vaginal deliveries, most places said residents were fine for vacuum numbers but only saw a few (if any) forceps deliveries.

 

[FutureDoc734]

There are a number of programs that will teach a good amount of forceps and vacuum (this was something that I was also particularly interested in when I researched programs to apply to), but you have to look for them. When you start interviewing, make sure to ask about it, and also ask your mentor for suggestions. Here are just a few academic programs that I visited and know to be comfortable in teaching forceps (I don't know if you have a geographic preference...):

- University of Texas at San Antonio (>99th percentile)
- UT Houston - LBJ
- Magee Womens Hospital of the UPMC (>97th percentile)
- University of Alabama at Birmingham (>99th percentile)
- Hopkins (>99th percentile)
- UNC at Chapel Hill
- Southwestern

Most academic programs will allow VBACs. Vaginal breech is more dependent on whether or not they can teach you rotational forceps - again, make sure to ask about it! Of course, a vag breech delivery is only done if mom comes in at 10 cm already and pushing or something, otherwise all the literature strongly encourages a C-sec.

Hope this helps.

 

[THP]

There really should not be any programs where you graduate not feeling comfortable with vacuum deliveries. Most should make leave you comfortable with forceps. I feel comfortable with both. You will do tons of breech deliveries at c/s. I'll be finishing residency in June having only done 5 vaginal breech deliveries. They were all breech extractions after baby A delivered vertex. (I'm not counting all of the pre-viable breeches and IUFDs) Assuming all of the proper criteria are met I will feel comfortable doing breech extractions for baby B next year. I can't imagine there is a single academic program that doesn't allow VBAC.

Also, FYI, rotational forceps have nothing to do with breech deliveries. There are piper forceps for delivering the head in a breech delivery. You probably won't learn rotational forceps any where you go, and you really shouldn't be doing them.

 

[anonperson]

There are a number of programs that will teach a good amount of forceps and vacuum (this was something that I was also particularly interested in when I researched programs to apply to), but you have to look for them. When you start interviewing, make sure to ask about it, and also ask your mentor for suggestions. Here are just a few academic programs that I visited and know to be comfortable in teaching forceps (I don't know if you have a geographic preference...):

- University of Texas at San Antonio (>99th percentile)
- UT Houston - LBJ
- Magee Womens Hospital of the UPMC (>97th percentile)
- University of Alabama at Birmingham (>99th percentile)
- Hopkins (>99th percentile)
- UNC at Chapel Hill
- Southwestern

Most academic programs will allow VBACs. Vaginal breech is more dependent on whether or not they can teach you rotational forceps - again, make sure to ask about it! Of course, a vag breech delivery is only done if mom comes in at 10 cm already and pushing or something, otherwise all the literature strongly encourages a C-sec.

Hope this helps.

These numbers are a bit misleading.

The absolute number of forceps in the country is dropping. If you check out the acgme numbers, 6 forcep deliveries puts you at the 50th percentile. Whether you are competent to do a forcep delivery after residency and deal with the potential consequences of mis applied forceps is individualized depending on a residents eagerness to learn them. Forceps are a dying art across the country and unfortunately it will be a matter of time before they are generally gone. I can say that my chiefs are comfortable performing outlet forceps but I'm not sure if they could effectively teach the skill to resident when they are attendings.

A rule of thumb is that programs in the south will have high forcep numbers compared to other regions.

Vaginal breech isn't related to rotational forceps. Vaginal breech is a tough one. You need to have the right situation, a patient comes in at 9cm with an adequate pelvis or is a multip and desires a vaginal delivery with failed version.

Nowadays most are getting sectioned or undergoing version so the vaginal breech numbers are low every where.

Like the previous poster stated, at the very minimum you should be able to throw on a vacuum in order to expedite a delivery if necessary. Sad thing is, vacuums are not benign devices and can cause some serious fetal harm but since they are so easy to apply they are the main operative tool nowadays.

Any place that isn't allowing a TOLAC for a patient with one prior C/D is being ridiculous, especially in light of the new guidelines. Hell, the guidelines say that a patient with 2 prior C/Ds may be a candidate for a TOLAC.

We just delivered a patient with 2 prior C/Ds vaginally without any issues or problems.. Of course attending comfort level is going to guide this.

 

[Geekchick921]

Any place that isn't allowing a TOLAC for a patient with one prior C/D is being ridiculous, especially in light of the new guidelines. Hell, the guidelines say that a patient with 2 prior C/Ds may be a candidate for a TOLAC.

We just delivered a patient with 2 prior C/Ds vaginally without any issues or problems.. Of course attending comfort level is going to guide this.

I completely agree, both as a future doctor and a patient. I thought it was ridiculous with the old guidelines really. Personally, my hospital VBAC with my son went so much more smoothly than the induction that led to the C-section with my daughter a few years prior.

That your hospital just had a VBA2C is awesome.

 

[GuzzyRon]

These numbers are a bit misleading.
Any place that isn't allowing a TOLAC for a patient with one prior C/D is being ridiculous, especially in light of the new guidelines. Hell, the guidelines say that a patient with 2 prior C/Ds may be a candidate for a TOLAC.

I respectfully disagree. Although I concur that disallowing TOLAC "right off the bat" is wrong but if risks such as infant macrosomia, unfavorable cervix, hx of previous uterine rupture, high risk of rupture, absence of adequate personnel and equipment, previous classic (or extended) incisions etc. exist, then TOLAC should NOT be attempted even if a patient has only had one or two prior CDs.

Here is what I'm trying to say: disallowing TOLAC following one or two prior CDs is NOT ridiculous if other serious maternal and perinatal risks or complications exist.

 

[anonperson]

I respectfully disagree. Although I concur that disallowing TOLAC "right off the bat" is wrong but if risks such as infant macrosomia, unfavorable cervix, hx of previous uterine rupture, high risk of rupture, absence of adequate personnel and equipment, previous classic (or extended) incisions etc. exist, then TOLAC should NOT be attempted even if a patient has only had one or two prior CDs.

Here is what I'm trying to say: disallowing TOLAC following one or two prior CDs is NOT ridiculous if other serious maternal and perinatal risks or complications exist.

What I meant is allowing TOLAC if the clinical situation is appropriate.

Some places, regardless of coverage situation will not allow a TOLAC even if the patient is a reasonable candidate. This is wrong.

A patient with a classical or prior uterine rupture or the other things you mentioned is generally by definition NOT a good candidate. This is fine and takes into account the clinical situation.

 

[FutureDoc734]

Also, FYI, rotational forceps have nothing to do with breech deliveries. There are piper forceps for delivering the head in a breech delivery. You probably won't learn rotational forceps any where you go, and you really shouldn't be doing them.

My bad! And, you're right about the percentiles being somewhat misleading, but I was just trying to give examples. I visited some programs where the residents graduated with over 50 (and some with even more than that) forceps deliveries under their belt (I'm not talking about percentiles here), and felt very comfortable with most of the different types. Overall, though, I definitely agree that the South is much more willing to use forceps versus North/Northeast residency programs, likely due to differences in litigation practices.

I did interview at a program that teaches rotational forces, btw, so it's not unheard of (yet...).

 

[GuzzyRon]

What I meant is allowing TOLAC if the clinical situation is appropriate.

Some places, regardless of coverage situation will not allow a TOLAC even if the patient is a reasonable candidate. This is wrong.

A patient with a classical or prior uterine rupture or the other things you mentioned is generally by definition NOT a good candidate. This is fine and takes into account the clinical situation.

Great! I feel it's necessary to state the contraindications as well lest some uninitiated pregnant woman s/p classical reading this runs off to her PCP demanding a TOLAC.

 

[Geekchick921]

Great! I feel it's necessary to state the contraindications as well lest some uninitiated pregnant woman s/p classical reading this runs off to her PCP demanding a TOLAC.

At which point she'd be denied and told why. I think this would likely be caught right away. Either the physician she's going to is the one that she saw for the previous pregnancy or her new provider should have her bring a copy of the operative report for the C/S to verify the type of incision. With VBAC's being as uncommon as they are, it's been my experience in talking to other hopeful VBAC patients that many have done at least a little bit of research on their own regarding their eligibility and chance of success. Anyway, I didn't get the impression that anonperson was suggesting a woman should have a TOL if she has an actual contraindication (to be fair, fetal macrosomia and unfavorable cervix alone are not according to the ACOG's guidelines). I often wonder how the hospitals that give reasons along the lines of ‘absence of adequate personnel and equipment' for denying VBAC patients manage other obstetrical compliations that require emegency C-section, but I digress…

Though it's more than 'some' places that don't allow them. This obviously varies by region but finding a hospital and provider is a complete road block in many cases, and even many hospitals (and physicians) that 'allow' VBAC patients aren't actually very supportive of them. It's unfortunate.

This is a soapbox issue for me on account of my own history and experience and the discussions I've had with many other women hoping to or have successfully had a VBAC. My apologies for possibly derailing the thread (further?).

 

[Miss Alyssa]

Thank's for all of the great input. I've heard of hospitals disallowing VBAC entirely. But I guess you guys are saying that the majority of hospitals with residency programs allow them. And I also shouldn't have to worry about vacuum numbers. So just forceps and vaginal breech...


One of the resident's here completed her ob/gyn residency in Czech. I was talking to her last night. She said that at her program she got a lot of training in vaginal breech and forceps. She also said there were a big push for VBAC (under the right conditions of course) and attempts to limit c-section. She did admit that the culture of law suits is different there.


It is kind of sad that some of our collective skills are being lost.

 

[sia_simba]

Very late response.

Not being able to use forcep is maybe for the better. If you must blame for lost art of forcep deliveries, then blame the lawyers.

Same thing goes for breech deliveries and TOLAC. at our hospital, patient's undergoing TOLAC actually sign two consents.

However, different area has different liability laws. In States where punishment for "undesired outcome" occurs is not in the 250 million dollars, physicians can practice the way they are taught and suppose to be.

In areas where its very high litigation (i.e. Kings County, Brooklyn NY), then majority of the physician whether ob/gyn, neurosurgery, or ER physician --> defensive medicine.

Thus goes our health care system.

 

[Requiem4Souless]

KU Wichita has excellent forceps delivery numbers, as well as many other procedures/surgeries. This is from their site:

Spontaneous Deliveries 676 99th
Forcep-assisted Deliveries 25 94th
Vacuum-assisted Deliveries 39 94th
Cesarean Deliveries 403 94th
Abdominal Hysterectomy 79 72th
Vaginal Hysterectomy 27 83th
Laparoscopy Hysterectomy 56 93rd