Resident Operative Vaginal Delivery Volume after Educational Curriculum Implementation

Abstract

Objective The percentage of operative vaginal deliveries (OVDs) in the United States has sharply declined. In May 2016, our institution's obstetrics and gynecology (OB/GYN) residency program implemented a twice-yearly OVD curriculum consisting of didactics and simulation. We sought to evaluate the impact of this curriculum. Study Design We performed a retrospective cohort study of all deliveries at our institution from July 2011 to May 2018. Deliveries were evaluated quarterly for the pre- (July 2011–April 2016) and postcurriculum (July 2016–May 2018) periods. Forceps-assisted vaginal delivery (FAVD), vacuum-assisted vaginal delivery (VAVD), and total OVD percentages, and the ratio of forceps to vacuums were calculated. Pre- and postcurriculum percentages were compared using Wilcoxon's rank-sum test. Cubic regression curves were fit to quarterly percentages to illustrate trends over time. Results The quarterly OVD percentage was unchanged following curriculum implementation (mean 3.2% [Q1–Q3: 2.6–3.5%] pre- vs. 3.1% [2.5–3.8%] post-, p > 0.99). The FAVD percentage was increased (1.2% [0.8–1.5%] vs. 2.0% [1.4–2.6%], p = 0.027) and the VAVD percentage was decreased (2.0% [1.6–2.2%] vs. 1.2% [0.9–1.3%], p < 0.001). This was accompanied by an increase in the ratio of FAVD to VAVD (0.6 [0.4–0.8] vs. 1.7 [1.3–2.2], p < 0.001). FAVD percentage (3.1%) was higher in the last quarter than any other quarter in the 7-year study period, and total OVD percentage (3.9%) was higher in 2018 than any other calendar year. Conclusion The implementation of an OVD curriculum in our OB/GYN residency program resulted in an increase in the percentage of FAVD and the ratio of FAVD to VAVD. Key Points

Reported case numbers and variability in delivery route and volume by obstetrics and gynecology residents from 2003 to 2019

“…Additionally implementation of formal OVD curricula have proven successful in increasing OVD rates within residency programs, and could be considered for widespread adoption. 17 In an analysis of outcomes of OVD performed by residents under the supervision of an attending obstetrician compared to outcomes when performed by the attending obstetrician alone, there was no difference in rates of neonatal or maternal morbidity. 18 Simulation models have developed to increase operator technique, comfort, knowledge, and patient outcomes.…”

Interventions to reintroduce or increase assisted vaginal births: a systematic review of the literature

“…In most of the studies that provided this information, significant increases in the rates of AVB were not associated with significant increases in adverse maternal or perinatal outcomes ( online supplemental file 8 ). Out of the five studies 27 38 39 43 44 conducted in HIC countries with statistically significant increases in the use of forceps, one 39 did not assess any maternal or perinatal outcomes, and one 38 reported non-significant changes in adverse maternal and perinatal outcomes (3rd/4th degree tears, low 5 min Apgar scores). The other three HIC studies 27 43 44 reported that increased rates of forceps were associated with either non-significant changes in several adverse maternal or perinatal outcomes (3rd/4th degree tears, birth injuries, overall neonatal complications, composite neonatal morbidity, low Apgar scores) or significant decreases in some of these outcomes (4th degree tears, overall maternal complications, postpartum haemorrhage, low cord pH) in this population.…”

“…The two studies that assessed participants’ changes in knowledge and skills (Kirkpatrick level-2) reported significant increases in these outcomes immediately after the training intervention. 39 47 Only one study assessed participants’ satisfaction with the intervention (Kirkpatrick level-1) and reported that the trainees (mostly midwives) reacted positively to all lectures and breakout sessions (mean scores 9.3/10). 47 None of the studies assessed maternal birth experience or satisfaction during the interventions.…”

Contemporary Trends in Cesarean Delivery Rates and Indications

“…25 A study conducted at our institution emphasized the importance of training residents on the utilization of forceps as an alternative to a cesarean delivery in the second stage of labor. 25 Fetal malpresentation is another indication that increases the cesarean rates. Breech presentation complicates around 4% of term deliveries; however, only one-third are offered an ECV, and if counseling does occur, some patients still refuse an ECV.…”

“…In addition to strictly conforming to the contemporary labor definitions, an increase in the utilization of operative vaginal delivery procedures is likely to decrease cesarean deliveries caused by second stage arrest. 3.3% of operative vaginal deliveries with 1.5% being forceps were performed at our hospital in 2016 compared to a national average of 3.1% operative deliveries and 0.5% forceps (25). A study conducted at our institution emphasized the importance of training residents on the utilization of forceps as an alternative to a cesarean delivery in the second stage of labor (25).…”