Reviving The Vanishing Art of Instrumental Vaginal Delivery in Tropical Obstetric Practice

Abstract

Dear Editor-in-Chief,

Our attention was drawn to a recent publication in the Tropical Journal of Obstetrics and Gynaecology TJOG) by Alu et al titled “Instrumental Vaginal Delivery in Abuja, Northcentral Nigeria: A 5-Year review”. We wish to commend the authors of this very illuminating manuscript, as it touches on a topical issue that is relevant to obstetric practice, not only in Nigeria, but globally.

The authors reported an instrumental delivery rate of 0.65% and cited other references that were published from different parts of Nigeria within the last decade.¹ These references reported IVD rates ranging between 0.4 to 2%.^2,3 These rates are quite low, compared to other countries globally such as the UK (up to 23%),⁴ and especially other sub-Sahara African countries (around 8%).⁵ These indices point to a low performance of this key skill in obstetric practice within the country. As a consequence, Caesarean section rates have increased geometrically in the country, further emphasizing the relevance of the skills for IVD as life-saving measures.

The implications of the low rates of IVD can be considered to be two-sided: first is the ongoing deprivation of the benefits of these life-saving procedures for women and babies who may benefit from them as a very crucial determinant of the outcome of their labour. This may also have resultant implications on the outcomes of future pregnancies. Secondly there is a high possibility that this trend will continue in the foreseeable future, as the currently low rates of IVD suggests that many specialists and their trainees would have neither observed nor performed enough of the procedures to achieve competence for independent practice. There is therefore the need to reverse the trends, in order to improve the intrapartum care of parturients in Nigeria to a level that is comparable to what obtains in order climes.

As doctors with clinical experience in both settings, we would like to propose practical approaches to a safe, improved and sustainable performance of IVD. There is a dire need for regular simulation training at local (Institutional) and national (Postgraduate Colleges) levels. For example, in the UK, the RCOG Operative Birth Simulation Training (ROBUST) is a mandatory requirement from early stage of specialty training in Obstetrics that provides a uniform training template for IVD.⁶ Furthermore, to achieve competence, a minimum number of workplace-based structured assessments should be a mandatory requirement for residents at different training levels, with formative and summative feedback to guide and improve proficiency.  This could be structured into non-rotational IVD for junior residents and rotational deliveries for senior residents, as obtainable in other training programmes globally.

One may ask how the already qualified specialists who are not fully equipped with the practical skills for IVD would teach the specialist trainees? This calls for a collaborative drive with the more-skilled colleagues. As the learning curve is expected to be steep, a hands-on training on the labour ward through partnership and exchange programmes will be more realistic than occasional training courses which are mostly manikin-based simulation drills.

Once achieved, consultant-led or consultant-delivered care at the teaching hospitals is the only way to sustain transfer of skills. The availability of consultants on the floor of the labour ward at all or most times of the day will provide the necessary support for specialty trainees to receive the experiential training and maintain the skills. Until these are considered, we will at best, regrettably continue to substitute IVDs with avoidable caesarean sections in the nation’s tertiary hospitals.