Simulation forceps training reduced severe perineal tearing by nearly 30 percent

Researchers at Northwestern University Feinberg School of Medicine identified 11 obstetricians at Northwestern Medicine's Prentice Women's Hospital, whom they called "forceps experts," with the highest rates of forceps usage and lowest rates of severe tears in the perineum, the tissue separating the vagina from the anus.

The training program was developed based on the best practices of these experts, then built into the residency curriculum and evaluated over two and a half years. The results of the study showed a dramatic decrease of 26 percent in the number of third and fourth degree perineal tears during forceps deliveries at Prentice Women's Hospital during resident-assisted deliveries from the previous seven years before the training began. The study results will be published in the September 2016 issue of the journal Obstetrics & Gynecology.

"We recognized there was a high number of severe lacerations with forceps and we looked for modifiable risk factors to lessen the injury rates," said Dana Gossett, MD, chief of the division of obstetrics and gynecology at Northwestern Memorial Hospital and the Feinberg School of Medicine. "Age, the weight of the baby, the position of the baby's head and how many babies someone has had are all factors in forceps deliveries. You can't change factors like the weight and size of a baby, so we looked at what we could change."

Investigators, including Dr. Gossett, first studied other variable birth factors to lessen perineal tears during forceps use, like modified positions of mothers during labor and effectiveness of warming pads on the perineum during labor. Neither resulted in a significant impact on perineal tears. That was when they turned to thinking anew about forceps training, which is not standardized throughout the obstetrics community, Dr. Gossett said.

While using simulation training has been used for teaching vaginal laceration repair or vaginal delivery of breech infants, there was not a specific model for using forceps to assist with a vaginal birth. Residents in the new training program typically spent less than three hours in a forceps lecture, followed by hands-on practice with a simulated model of a woman in labor, before an instructor determined they mastered the skill.

Forceps are not used at all hospitals, Dr. Gossett said, in part because the skill has been lost as obstetricians stopped using them, which may have contributed to the increase in caesarean sections. Forceps can help a woman safely deliver a baby without a caesarean section, which has a substantially higher rate of maternal morbidity and mortality than vaginal delivery.

Forceps use is not without risk, however, including vaginal tearing that can lead to urinary or fecal incontinence, pain, infection or loss of sexual function for the mother.

"Patients had better birth outcomes with obstetrics residents who are trained in forceps techniques," said Dr. Gossett. "We believe our simulation training program is an easily replicated, low-cost way to minimize perineal tears during vaginal births that require forceps."