DOI: 10.1111/1471-0528.

12199 Intrapartum care

www.bjog.org

A re-evaluation of the role of rotational forceps:

retrospective comparison of maternal and
perinatal outcomes following different methods
of birth for malposition in the second stage of
labour
N Tempest,a A Hart,b S Walkinshaw,a DK Hapangamaa,c
a
Liverpool Women’s Hospital NHS Foundation Trust, Liverpool, b Division of Medicine, University of Lancaster, Lancaster, c Department of
Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
Correspondence: Dr DK Hapangama, Department of Women’s and Children’s Health, Institute of Translational Medicine, University
Department, Liverpool Women’s Hospital, Crown Street, Liverpool L8 7SS, UK. Email dharani.hapangama@liverpool.ac.uk

Accepted 12 January 2013. Published Online 21 March 2013.

Objective To compare the outcomes of operative cephalic births maternal (massive obstetric haemorrhage—blood loss of
by Kielland forceps (KF), rotational ventouse (RV), or primary >1500 ml, sphincter injury, length of stay in hospital) safety
emergency caesarean section (pEMCS) for malposition in the outcomes were also recorded.
second stage of labour in modern practise.
Results Women were more likely to need caesarean section if RV
Design Retrospective observational study. (22.4%) was selected to assist the birth rather than KF (3.7%;
adjusted odds ratio 8.20; 95% confidence interval 4.54–14.79).
Population Data were included from 1291 consecutive full-term,
Births by KF had a rate of adverse maternal and neonatal
singleton cephalic births between 2 November 2006 and 30
outcomes comparable to those by RV and pEMCS in the second
November 2010 with malposition of the fetal head during the
stage for malposition.
second stage of labour leading to an attempt to deliver by KF, RV
or pEMCS. Conclusions Our results suggest that, in experienced hands,
assisted vaginal birth by KF is likely to be the most effective and
Methods Maternal and neonatal outcomes of all KF births were
safe method to prevent the ever rising rate of caesarean sections
compared with other methods of operative birth for malposition
when malposition complicates the second stage of labour.
in the second stage of labour (RV or pEMCS).
Keywords Emergency caesarean section, Kielland forceps,
Main outcome measures Achieving a vaginal birth was the
rotational vaginal birth, rotational ventouse.
primary outcome and fetal (admission to special care baby unit,
low cord pH, low Apgar, shoulder dystocia, Erb’s palsy) and

Please cite this paper as: Tempest N, Hart A, Walkinshaw S, Hapangama D. A re-evaluation of the role of rotational forceps: retrospective comparison of
maternal and perinatal outcomes following different methods of birth for malposition in the second stage of labour. BJOG 2013;120:1277–1284.

and reduce the rates of CS.2 There are increased maternal

Introduction
Rising caesarean section (CS) rates are a global concern.1–3
In the UK, CS rates have doubled from 1990 to 2008 (12–
24%) and in the USA, CS accounts for almost a third of
births4 with no improvement in outcomes for the baby.3
The rates of CS during the second stage of labour are also
increasing.1,5 The American College of Obstetricians has
recommended training in instrumental births to control
and neonatal risks with CS undertaken at full dilatation1,5–11
yet the perception remains that this is a better option than
a potentially ‘difficult’ vaginal operative birth.2,5,12,13
Assisted vaginal operative births are traditionally linked
with increased risk of major fetal trauma,2,14–18 ranging
from brachial plexus injury to intracranial haemorrhage
and skull fractures, yet the risk of fetal trauma is also
increased for CS performed during labour14,19 with cerebral

ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG 1277
 Tempest et al.
haemorrhage and convulsions as likely following CS in
labour.20 In urgent births the risk of death was calculated
at 0.8 per 1000 births for emergency CS (EMCS) whereas
the vacuum and forceps births carried a risk of 0.5 and 0.6
per 1000, respectively.14
Malposition of the fetal head is the commonest indica-
tion for CS in the second stage of labour. There is no cur-
rent evidence from randomised trials to inform best
practice for delivery when malposition complicates the sec-
ond stage.6,13 The only data available from the last two
decades are small case series reporting limited outcomes of
rotational births.2,8–12,15,20–31
The most commonly used method for birth when mal-
position delays delivery is rotational ventouse (RV).32
However, the use of RV is four times more likely to fail to
deliver the baby when compared with nonrotational
ventouse birth.10 Furthermore, ventouse use is associated
with a 60 times higher risk of sub-aponeurotic haemor-
rhages than with other modes of childbirth.17 The negative
publicity received by Kielland forceps (KF)2,15,33 has
resulted in a dramatic reduction in their use. A parallel
increase was seen in the use of RV and EMCS as alternative
delivery methods of choice in many maternity units in the
UK.1,2,5
This retrospective observational study aims to provide
contemporary, comparative outcome data for women and
babies where malposition of the fetal head complicated the
second stage of labour. This study therefore includes
attempted birth by KF, RV and EMCS without attempt at
vaginal operative birth.
Methods
Setting
Liverpool Women’s Hospital (LWH) has around 8500
births per annum and is a tertiary referral centre with level
three neonatal intensive care facilities. The LWH labour
ward is directly supervised by a senior registrar with at
least 6–7 years of specialist training in obstetrics 24 hours
a day. In addition, there will be at least one junior registrar
(with a minimum of 3 years of specialist training) and an
early career trainee with less than 3 years specialist train-
ing. Throughout the study period, there was at least
60 hours per week of direct consultant presence. For the
last 12 months of the study period, direct consultant pres-
ence was increased to 90 hours per week. Outwith these
periods there was always indirect consultant supervision.
In addition, local guidelines mandated that all births for
malposition in the second stage should be directly super-
vised or conducted by an experienced obstetrician (senior
registrar with at least 6–7 years of specialist training in
obstetrics or a consultant) throughout the study period.
All senior trainees were directly supervised by consultant
1278 ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG
staff before being deemed competent and able to supervise
other trainees.
Participants
We examined the maternal and neonatal outcomes follow-
ing different methods of operative births in the second
stage of labour when malposition of the fetal head is the
reason for the delay. In all, 265 births where manual rota-
tion was used to correct malposition were excluded from
this (intention to deliver) analysis because of the incom-
plete nature of recording for these births.
Case identification and data validation
For the 50-month period from 2 November 2006 to 30
November 2010, all assisted rotational vaginal operative
births and EMCS in the second stage for delay associated
with malposition were retrospectively reviewed. The
computerised hospital database, Meditech, at the LWH
and the LWH birth registry kept in the labour ward were
used to identify the relevant women and the computerised
data were collected as part of an ongoing prospective
audit since 2006. Demographic and outcome data, as
described below, were collected. The computerised data
were verified with reference to the risk management
database (maternal haemorrhage [blood loss >1500 ml],
failed instrumental birth, low cord pH, low Apgar score,
unexpected admission of term babies to special care
baby unit [SCBU], shoulder dystocia), local transfusion
database (massive obstetric haemorrhage), postnatal
perineal clinic data (sphincter trauma) and the neonatal
computerised database (BADGER; all neonatal outcomes)
and neonatal clinic data on follow up of babies with Erb’s
palsy 12 months following delivery. In addition, the data
were verified in 735 sets of paper clinical records
randomly selected (on average at a rate of 15 case notes
per month) during the study period. The final data
set was entered into an EXCEL spreadsheet and migrated
into INTERCOOLED STATA 11.2 for analysis. Ethical approval
was not required for this continuous audit, for which
approval was granted by directorate audit committee at
LWH.
Demographics and other confounders
The following demographic variables were collected;
woman’s age at birth, maternal body mass index at book-
ing, parity, length of first and second stages of labour,
whether the labour was induced, if an epidural was sited,
evidence of coexisting fetal compromise as the reason for
assisted birth (fetal distress ascertained with cardiotocogra-
phy only, fetal distress ascertained with both cardiotocogra-
phy and fetal scalp pH, antepartum haemorrhage and cord
presentation), operator seniority and birthweight. The
categories of delivery method were; KF, RV, and primary

emergency caesarean section in the second stage associated
with malposition (pEMCS).
We considered the factors that may have influenced
both the choice of method employed to assist birth and
the potential outcomes, for example, a diagnosis of poten-
tial fetal compromise (fetal distress ascertained by cardiot-
ocographic abnormality only, fetal distress ascertained with
both cardiotocography and fetal scalp pH, antepartum
haemorrhage and cord presentation) as a coexisting indi-
cation for urgent birth will affect neonatal outcomes and
may affect the choice of mode of delivery. Similarly, the
operator seniority may affect failure rates of procedure
and outcomes. There is evidence that epidural analgesia
during labour increases vaginal operative birth rates.34
Prolonged second stage has been associated with reduced
cord pH values and Apgar scores.35,36 Birthweight influ-
ences success rates of operative vaginal birth,8 in addition
to increasing other outcome measures such as shoulder
dystocia, sphincter injury and haemorrhage.
Outcome variables collected
The primary, clinically significant outcome selected was the
success of the method used in achieving a vaginal birth
and so avoiding an EMCS. Maternal and neonatal out-
comes were chosen for their important clinical relevance,
associated morbidity for the mother and baby and cost
implications for the NHS and society in general.
Maternal outcome variables collected were; maternal
haemorrhage (blood loss of >1500 ml), anal sphincter
injury and length of hospital stay. Neonatal outcome vari-
ables collected were; admission to SCBU, incidence of
babies with cord pH at delivery <7.1, Apgar score <5 at
5 minutes, incidence of shoulder dystocia and Erb’s palsy.
Outcomes such as the length of maternal hospital stay and
admission to SCBU were collected for their important cost
implications for the NHS.
Statistical analysis
We carried out an ‘intention to deliver’ analysis of the neo-
natal and maternal outcomes, where the outcomes were
categorised according to the initially intended method of
operative birth when delay as a consequence of fetal mal-
position was diagnosed.
Where appropriate, linear or logistic regression was used to
compare outcomes by intended delivery group. This com-
prised unadjusted analyses and analyses adjusted for all previ-
ously identified confounding factors. Because of the presence
of missing values, the number of ‘complete cases’ for adjusted
analyses was often lower than for the corresponding unad-
justed analyses. Simple robustness checks were therefore car-
ried out by repeating unadjusted analyses on the ‘complete
cases’ for that outcome. Fisher’s exact test or Kruskal–Wallis
test was used when regression was not possible.
ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG
Future of Kielland births
Results
Demographic data
There were 34 198 babies born at the Liverpool Women’s
Hospital between 2 November 2006 and 30 December
2010. Of these, 21 259 were normal vaginal births, not
requiring assistance (62.2%); 3497 babies were delivered by
planned elective caesarean sections (10.2%); 4530 births
were by EMCS (13.2%), 667 of those were performed at
full dilatation (1.95%); out of which 146 were performed
for the primary indication of delay in second stage of
labour due to fetal malposition without a trial of instru-
mental delivery (pEMCS 0.4%).
There were 4491 operative vaginal births (13.1%).
We included the data from 1291 consecutive full-term
singleton cephalic births between 2 November 2006 and 30
November 2010 with malposition of the fetal head during
the second stage of labour. This data set includes 1038
attempted KF (80.4%), 107 attempted RV (8.3%) and 146
pEMCS (11.3%).
Demographic data between groups are summarised in
Table 1.
Maternal age, duration of first stage of labour, rates of
epidural analgesia in labour and the seniority of the opera-
tor were similar among women in the different groups.
Statistical differences were noted between the study
groups within the following variables: maternal body mass
indices, multiparity, induction of labour, duration of sec-
ond stage of labour, evidence of coexisting fetal compro-
mise as a secondary indication for birth and birthweight.
Primary outcome
The odds of women needing caesarean section were eight
times higher if RV was selected to assist the birth rather
than KF (odds ratio 8.20; 95% CI 4.54–14.79). The use of
KF resulted in a failure of vaginal birth in only 3.7% (38/
1038) of women.
Secondary outcomes for all attempted KF and RV
The results for maternal outcomes are shown in Table 2.
The small numbers of RV in the study do not allow sta-
tistical comparison for the secondary maternal outcomes.
The number of days of stay in hospital postnatally and the
incidence of maternal haemorrhage were higher following
birth by KF. The incidence of recognised anal sphincter
injury with KF was 25/1037 (2.4%).
Neonatal outcomes
Other than an apparently more frequent (not statistically
significant) incidence of neonates with an Apgar score at 5-
minute <5 in women undergoing pEMCS (3/146; 2.1%)
compared with KF (1/1036; 0.1%) and RV (1/107; 0.9%),
no differences in neonatal outcomes were observed.
1279
 Tempest et al.

Table 1. Demographic data by planned delivery method

Variable Kielland forceps (n = 1038) Rotational ventouse (n = 107) EMCS second stage (n =146)

Maternal age 28.8 (5.7) 29.8 (6.0) 29.7 (6.0)

Referent 0.98 ( 0.17 to 2.13) 0.87 ( 0.15 to 1.90)
Maternal body mass index 25.3 (4.8) 25.2 (5.7) 26.8 (5.9)*
Referent 0.13 ( 1.15 to 0.88) 1.47 (0.59 to 2.35)
Multiparity 177/1038 (17.1%) 25/107 (23.4%) 17/146 (11.6%)
Referent 1.48 (0.92 to 2.39) 0.64 (0.37 to 1.09)
Induction of labour 346/1038 (33.3%) 44/107 (41.1%) 60/146 (41.1%)
Referent 1.40 (0.93 to 2.10) 1.40 (0.97 to 1.99)
Epidural 491/1037 (47.3%) 48/107 (44.9%) 78/146 (53.4%)
Referent 0.90 (0.60 to 1.35) 1.28 (0.90 to 1.81)
Duration of first stage 563.5 (325.0) 507.8 (263.9) 598.4 (292.8)
of labour**** Referent 55.7 ( 120.7 to 9.4) 34.9 ( 33.0 to 102.9)
Duration of second stage 194.0 (76.1) 145.7 (84.8) 216.5 (71.2)***
of labour**** Referent 48.3 ( 63.7 to 32.7) 22.5 (6.1 to 38.9)
Co-existing diagnosis of potential 146/1038 (14.1%) 36/107 (33.6%)*** n/a
fetal compromise***** Referent 3.10 (2.00 to 4.80) n/a
Operator (ST5 or above) 669/1033 (64.8%) 66/105 (62.9%) 88/143 (61.5%)
Referent 0.92 (0.60 to 1.40) 0.87 (0.60 to 1.25)
Birthweight 3536.1(492.7) 3447.0 (554.9) 3658.4 (584.0)**
Referent 89.1 ( 190.5 to 12.3) 122.3 (34.0 to 210.6)

Data are mean (SD) and mean difference (95% confidence interval) or proportion (%) and odds ratio (95% confidence interval) with Kielland
forceps as the reference group.
*P = 0.004; **P = 0.003, ***P  0.001.
****Based on incomplete numbers (92 emergency caesarean section, 101 and 103 ventouse, 1014 and 1021 Kielland forceps).
*****Potential fetal compromise is defined by fetal distress ascertained with cardiotocography (CTG) only, fetal distress ascertained with both
CTG and fetal scalp pH, antepartum haemorrhage and cord presentation.

Admission rates to SCBU were similar between the Maternal outcomes

groups; 10.3% of the KF group (107/1038), 12.1% of the
RV group (12.1%) and 11% of the pEMCS group (16/146).
The rates of cord pH <7.1 were also similar valthough
caution is needed over interpretation of these data because
values are missing; 6.3% KF (56/882), 5.6% RV (5/90) and
6.2% pEMCS 8/129. Furthermore, the rates of admission to
SCBU of the missing cord pH group was similar to that of
the normal pH group (pH > 7.1).
Births by KF were associated with a nonsignificant increase
in the rate of shoulder dystocia (64/1038; 6.2%) compared
with RV deliveries (4/107; 3.7%). Transient Erb’s palsy
complicated 1% of KF births (10/1038) and none of the RV
births. All infants diagnosed with Erb’s palsy were followed
up for 12 months by the neonatologists and none had long-
term or residual complications.
Adjusted analyses confirmed these trends, and the robust-
ness checks did not alter the conclusions (data not shown).
Outcomes for successful versus unsuccessful
rotational deliveries
Outcome data were also analysed by actual method of
birth, allowing the examination of outcomes following
unsuccessful attempts of KF or RV.
The incidence of maternal haemorrhage (blood loss of
>1500 ml) was highest for women who underwent a failed
attempt of instrumental birth and subsequently had an
EMCS—7.9% for failed KF (3/38) and 4.2% for failed RV
(1/24). The incidence of maternal haemorrhage following
pEMCS was 2.1% (3/146), which is comparable with the
women who had successful KF (1.7%; 17/999) and RV
(1.2%; 1/83) births.
Women who had a successful RV had the shortest stay
in hospital with a median of 2 days compared with a
median stay of 3 days following successful KF. The women
who had pEMCS and the women who underwent a failed
attempt of instrumental birth proceeding to EMCS had the
same median duration of hospital stay at 4 days.
Neonatal outcomes
The babies who were born by EMCS after a failed attempt
of an instrumental delivery had the highest rate of admis-
sion to SCBU at 16.1–13.2% (5/38) for failed KF and
20.8% (5/24) for failed RV—higher than any of the other
groups studied. Eleven percent of babies who were deliv-
ered by pEMCS (16/146) were admitted to SCBU. The
admissions to SCBU following successful KF or successful

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 Future of Kielland births

Table 2. Maternal and neonatal outcomes by planned delivery group

Maternal or neonatal outcomes Kielland forceps Rotational ventouse Emergency caesarean

(n = 1038) (n = 107) section (n = 146)

Caesarean section 38/1038 (3.7%) 24/107 (22.4%) 146

Unadjusted OR Referent 7.34 (4.13–13.05)*
Adjusted OR** Referent 8.20 (4.54–14.79)
Massive obstetric haemorrhage 19/1037 (1.8%) 2/107 (1.9%) 3/146 (2.1%)
Unadjusted OR Referent 0.60 (0.07–4.5) 1.30 (0.30–5.72)
Adjusted OR*** Referent 0.74 (0.09–5.78) 1.19 (0.25–5.45)*****
Sphincter injury 25/1037 (2.4%) 0/107 Not applicable
Type of sphincter injury
Third-degree partial 19/1037 (1.83%) Not applicable Not applicable
Third-degree complete 4/1037 (0.39%)
Fourth-degree 2/1037 (0.19%)
Maternal hospital stay (days or part days) Median (IQR)**** 4 (3–5) 4 (3–5) 5 (4–6)*
Neonatal admission to special care baby unit 107/1038 (10.3%) 13/107 (12.1%) 16/146 (11.0%)
Unadjusted OR Referent 1.20 (0.65–2.22) 1.07 (0.61–1.87)
Adjusted OR** Referent 1.09 (0.58–2.03) 1.16 (0.66–2.04)

IQR, interquartile range.

Data are proportion (%) unless otherwise stated. Odds ratios (OR) are unadjusted and adjusted for identified confounding factors.
*P < 0.001.
**Adjusted for body mass index, multiple gestation, birthweight, seniority (ST5 or above), a coexisting diagnosis of potential fetal compromise
(n = 1113).
***Adjusted for body mass index, multiple gestation, birthweight, length stage 1 and length stage 2, a co-existing diagnosis of potential fetal
compromise (n = 1177).
****Incomplete data (1026 Kielland forceps, 105 ventouse, 141 caesarean section).
*****Result may be unreliable because length of second stage of labour is missing for 37% of women with primary emergency caesarean section.

RV births were comparable at 10.2% (102/1000) and 9.6%
(8/83), respectively.
Following admission to SCBU the median durations of
stay were similar between the groups; 3 days (range 1–
41 days) following successful KF, 2 days (range 1–4 days)
following failed KF, 3.5 days (range 2–21 days) following
successful RV, 3 days (range 1–19 days) following failed
RV and 2.5 days (range 1–24 days) following pEMCS.
The incidence of low umbilical cord pH (<7.1) was highest
in the failed KF group (11.4%; 4/35) and the successful RV
group (7.2%; 5/69). The proportion of neonates delivered by
successful KF and pEMCS with low umbilical cord pH were
similar—6.1% (52/847) and 6.2% (8/129), respectively.
The proportion of neonates born with Apgar scores <5
at 5 minutes were low in all of the study groups: 0.1% (1/
998) of the successful KF group, 4.2% (1/24) of the failed
RV group and 2.1% (3/146) of the pEMCS group. No
babies were recorded to have an Apgar <5 at 5 minutes in
the failed KF and the successful RV groups.
Discussion
Main findings
We found that, compared with other available methods for
birth complicated with fetal malposition, KF in experienced
hands was associated with a higher chance of achieving a
vaginal birth without a significant increase in neonatal
morbidity or mortality. This finding is novel and important
in formulating frameworks to deliver high-quality obstetric
care. Furthermore, this observation is consistent with other
reports comparing rotational forceps (KF) with pEMCS in
the second stage of labour11,18–21,25,27 and other modern
series reporting high success rates for vaginal birth using
KF as the first instrument (96.3%) when compared with
RV.18,21,22 Our data further confirm that neonatal and
maternal morbidity is increased in unsuccessful instrumen-
tal vaginal birth with relatively high rates of maternal
haemorrhage and admissions of babies to SCBU.6,10,19,23
These data emphasise the importance of using a method
that is most likely to be successful in achieving a vaginal
birth for the benefit of both the mother and the baby. After
failed operative birth, the highest risk to the baby is when
multiple instruments are employed to achieve the
birth6,8,14,16,22,23,25 and it is therefore logical to consider the
most effective instrument as the first choice to assist a
birth, unless there are specific safety concerns.
All vaginal births at our unit carried a 1.5% risk of anal
sphincter injury during the study period. Forceps birth has
been associated with an increased risk of sphincter trauma,
with rates of 7% being described.37 The observed rates of

ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG 1281
 Tempest et al.
2.5% for KF and 0% for RV for this study are low, and may
be a consequence of the high levels of training and supervi-
sion that exist in our unit. The unit also has a long-standing
interest in sphincter trauma38 and an enhanced awareness of
the need for appropriate episiotomy and conduct of birth of
the head. The presence of senior obstetricians (more than
6 years in the specialty) at each birth may also contribute to
the low rate. Considering our retrospective data set, we can-
not formally calculate the exact number of EMCS avoided or
the number of extra sphincter trauma caused for each KF
birth that would replace an RV. Recent national data from
Finland on anal sphincter injury following all ventouse births
has reported a rate of 3.3% for nulliparous women and 1.4%
for multiparous women.39 Such figures if required can only
be accurately calculated by using data from a randomised
control trial or at least using data from a prospective obser-
vational study with adequate sample size and they are desir-
able to provide clinicians and NHS service providers with the
cost implications to plan their future service delivery.
Obstetricians usually choose a method of rotational birth
early in their training and usually will then obtain the nec-
essary skills in performing this chosen method of assisted
rotational birth. Furthermore, all obstetricians are capable
of performing CS should their method of choice of assisted
vaginal birth be unsuccessful. In the study, consultant staff
reflected this with six exclusively using and teaching KF,
four exclusively the ventouse and six using both. A large
number of obstetric trainees performed the births (75 for
KF and 35 for RV) with 44.8% of KF and 60% of RV actu-
ally performed by senior trainees or consultants. The other
births, by less senior trainees, were directly supervised by
senior staff with their specific preferences. Choice of instru-
ment therefore reflected strongly the preference of the duty
team rather than the clinical situation, though we cannot
exclude a small number of cases where a degree of selection
took place. As a consequence we feel it is unlikely that the
results for KF reflect selection bias or the practice of a few
highly skilled individuals.
Strengths
This is the largest reported series of rotational, operative
vaginal births from a modern, tertiary obstetric unit where
data for all the operative modes for malposition of the fetal
head are available.
The choice of instrument is almost exclusively operative
preference driven. This spread of experience and preference
coupled with the large number of practitioners reduces the
chance that selection bias has enhanced the performance of
KF.
Weaknesses
The retrospective nature of data collection is the main
drawback of this study. For example, we were unable to
1282 ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG
retrieve reliable data on attempts of manual rotation fol-
lowed by normal vaginal delivery or the use of a second
instrument as such interventions are not routinely recorded
in either the case-notes or the computerised database.
Given the large number of outcomes considered, and the
consequent problems of multiple testing, any P-values/con-
fidence intervals need to be interpreted with caution. How-
ever, the study could not be powered for all outcomes and
therefore, it is the trends in the data that are highlighted. A
further deficiency of this study is the lack of information
on the subjective but important information on the station
of fetal head, presence of caput, strength of uterine con-
tractions and findings of the abdominal examination. This
information should be collected in future prospective
multicentre cohort studies to assess the best method of
birth for malposition.
Interpretation
Our data show that the use of KF is associated with a low
incidence of complications for both the woman and the
infant and compares favourably with other techniques. This
is not a result of selection bias or a result of the skills of a
few individuals. The fall from favour of KF was based on
small studies15,19,21,40 that did not compare rotational for-
ceps with other operative methods of birth complicated
with malposition at full dilatation. Conversely, many other
studies2,22,23 demonstrated similar fetal outcomes with KF
to CS at full dilatation. In many healthcare settings com-
plex vaginal operative birth is regarded as too risky with
recourse to second-stage EMCS. This study, and
others,1,7,11,19,21,22,28 show that there is no clear benefit to
either woman or infant in this approach with, if anything,
higher incidence of morbidities except for sphincter injury.
Occipito-posterior position of the fetal head is known to
increase the risk of sphincter injury and this risk is reduced
by correcting malposition by rotation and completing the
delivery in the occipito-anterior position.41 We would add
a caveat that our findings are observed within a specific
setting where all operative techniques were either per-
formed or directly or indirectly supervised by a group of
UK consultants, most of whom are whole time obstetri-
cians providing ongoing support and training for trainees.
The low rate of sphincter damage may be another conse-
quence of this degree of senior supervision.
Conclusion
These results should encourage clinicians to re-evaluate
their choice of instrument for rotational birth, and should
encourage professional bodies to reconsider training
opportunities for this type of birth. The practise of
rotational deliveries we report here does not seem to be
unusual in the UK. A number of other large units in the

UK have a similar large proportion of rotational forceps
births.42
As the use of KF was associated with a high probability
of achieving a vaginal birth, advanced obstetrics training
should include opportunities for the trainees to achieve
training in this method of birth.5,8,18,22,39 Rotational vaginal
birth of all types is an advanced surgical procedure. There
are many models across specialties on how such advanced
procedures can be taught and disseminated into all settings,
and these include the opportunity for existing specialists to
acquire such techniques and take them back to their base
hospital.43,44 Guidelines and training programmes should
be developed for performing, training and documenting
these deliveries, which require the highest level of skills in
acute obstetrics practise. In the UK, and we suspect else-
where, there are sufficient practitioners to allow a safe
phased re-introduction of rotational forceps.
We conclude that our study highlights the urgent need
for national prospective data collection of the outcomes of
high-risk obstetrics interventions such as second-stage CS
and rotational deliveries.
Disclosure of interests
All authors declare no conflict of interest.
Contribution to authorship
DKH obtained the audit approval, and supervised the
conduct of the audit. DKH and SAW conceived the manu-
script design. NT and DKH collected the data, analysed/
interpreted the data and produced the first draft. AH
carried out statistical analysis. SAW was involved in data
interpretation, and revised the manuscript critically for
important intellectual content. All authors read and
approved the submitted version of the manuscript.
Details of ethical approval
The data were collected as part of the ongoing audit
programme at the LWH, for which approval was granted by
directorate audit committee at LWH. The project was
reviewed by the LWH R&D Department and the anonymised
data set was deemed to be exempt from requiring ethics
approval from an independent research ethics committee
because it was agreed with reference to NRES guidance for
defining research to be audit and not research.
Funding
Support for the authors was supplied by the Liverpool
Women’s Hospital NHS Trust and the University of
Liverpool.
Acknowledgements
Authors are grateful to Mrs Sandra Drummond (Informa-
tion technology project midwife), Mrs Jane Saltmarsh
ª 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2013 RCOG
Future of Kielland births
(Information technology, BADGER system), Mrs Sue Orch-
ard (Divisional Risk Lead for Maternity, Neonates and
Clinical services), Drs Helen Scholefield (Consultant Obste-
trician, Risk management lead and the clinical director for
the study duration at the LWH), Aileen Cope, Ausha De
Silva, Sartorious Karagolopolou and Chirag Patel for their
assistance in data collection. The authors also wish to
acknowledge the constructive comments on the manuscript
by Professors Zarko Alfirevic and James Neilson. &
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