European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 333–340

Decision-making in operative vaginal delivery: when to intervene,where to deliver and which instrument to use? Qualitative analysis ofexpert clinical practice

Rachna Bahl a,*, Deirdre J. Murphy b, Bryony Strachan a

a St. Michael’s Hospital, Bristol, United Kingdomb Academic Department of Obstetrics & Gynaecology, Coombe Women & Infants University Hospital & Trinity College, University of Dublin, Dublin 8, Ireland

A R T I C L E I N F O

Article history:

Received 25 June 2012

Received in revised form 16 April 2013

Accepted 15 June 2013

Keywords:

Operative vaginal delivery

Place of birth

Choice of instrument

Technical skill

Qualitative study

A B S T R A C T

Objective: To identify the decision-making process involved in determining when to intervene, where to

deliver and the optimal choice of instrument for operative vaginal deliveries in the second stage of

labour.

Study design: A qualitative study using interviews and video recordings took place at two university

teaching hospitals (St. Michael’s Hospital Bristol and Ninewells Hospital, Dundee). Ten obstetricians and

eight midwives were identified as experts in conducting or supporting operative vaginal deliveries.

Semi-structured interviews were carried out using routine clinical scenarios. The experts were also video

recorded conducting low cavity vacuum and mid-cavity rotational forceps deliveries in a simulation

setting. The interviews and video recordings were transcribed verbatim and analysed using thematic

coding. The anonymised data were independently coded by three researchers and then compared for

consistency of interpretation. The experts reviewed the coded interview and video data for respondent

validation and clarification. The themes that emerged following the final coding were used to identify the

decision-making process when planning and conducting an operative vaginal delivery. Key decision

points were reported in selecting when and where to conduct an operative vaginal delivery and which

instrument to use.

Results: The final decision-making list highlights the various decision points to consider when

performing an operative vaginal delivery. We identified clinical factors that experts take into

consideration when selecting where the delivery should take place and the preferred choice of

instrument.

Conclusion: This detailed illustration of the decision-making process could aid trainees’ understanding

of the approach to safe operative vaginal delivery, aiming to minimise morbidity.

� 2013 Elsevier Ireland Ltd. All rights reserved.

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1. Introduction

Operative vaginal deliveries account for 11–13% of all births inthe UK [1,2]. The decision to conduct an operative vaginal deliveryis often made by a trainee obstetrician after prompting by amidwife. In a significant proportion of cases more than one courseof action may be justifiable including watchful waiting [3]. Whenoperative vaginal delivery is indicated, it is recommended byclinical guidelines that the operator should select the instrumentmost appropriate to the clinical circumstances and their level ofskill [4]. The operator must also decide where the attemptedoperative vaginal delivery should take place. It is recommended

* Corresponding author at: Obstetrics and Gynaecology, St. Michael’s Hospital,

Bristol BS2 8EG, United Kingdom. Tel.: +44 117 3425594.

E-mail address: rachnabahl@hotmail.com (R. Bahl).

0301-2115/$ – see front matter � 2013 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ejogrb.2013.06.033

that operative vaginal deliveries that have a higher rate of failureshould be conducted in a place where immediate recourse tocaesarean section can be undertaken (usually within an operatingtheatre) [4].

When planning an intrapartum intervention it is important foran individual obstetrician to develop a stepwise decision-makingscheme that can be consistently applied when a clinical situationarises. In current training, the emphasis is placed on theindications, contraindications and prerequisites for operativevaginal deliveries, with little emphasis on the decision-makingprocess. This may be because these tacit skills are not readilyidentifiable during observation of a procedure. Within the clinicalsetting, decision-making about when to intervene, where toconduct the delivery, and what instrument to use is learntexperientially, often by trial and error. A trainee learns decision-making skills from observation of expert obstetricians and peers.The expert, however, may not always be able to articulate all the

R. Bahl et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 333–340334

factors he or she has evaluated whilst making the decisions [5,6].The technique of cognitive task analysis (CTA) allows theresearcher to investigate in detail the various decision points ina task and the factors affecting the decision-making process [7,8].This technique has been used to investigate non-technical skills inanaesthesia and surgery [9,10] and we have previously exploredthis approach in relation to low cavity non-rotational vacuumdelivery [11].

In this study we aimed to use CTA to identify the decision-making processes involved in deciding when to deliver, where todeliver and which instrument to use following assessment of thewoman for operative vaginal delivery in the second stage of labour.

2. Materials and methods

The study was based at two UK university teaching hospitals:St. Michael’s Hospital, Bristol, and Ninewells Hospital and MedicalSchool, Dundee. St. Michael’s Hospital has over 5000 deliveries peryear and Ninewells Hospital has almost 4000 deliveries per year.Both units are actively involved in teaching undergraduates andpostgraduates and organising the specialist registrar trainingprogramme (postgraduate specialist training). Both units arecomparable in terms of background obstetric practice. They havesimilar rates of induction of labour, use of epidural analgesia,operative vaginal deliveries and caesarean sections. By involvingtwo units from different training regions we aimed to eliminate theinstitutional bias towards a particular practice and thereforeincrease generalisability. The participating expert obstetricianscompleted their training in units from six deaneries acrossEngland, Scotland and another two European countries, furtheradding to the generalisability of the research findings.

The participants for this study were purposively sampled toallow selection of individuals with in-depth knowledge andexpertise in operative vaginal deliveries. For the purpose of thisstudy we define an expert obstetrician as someone who isrespected by their peers for his/her expertise in conductingoperative vaginal deliveries. We have selected the experts based onreputation because we believe that the number of proceduresperformed or morbidity data for individual obstetricians would notprovide a true representation of expertise. The experts performfewer deliveries but these deliveries are often more complex thanusual and therefore have a greater inherent risk of morbidity.Senior midwives working on the labour ward have witnessednumerous obstetricians performing operative vaginal deliveriesand have formed an opinion about the expert ability of individualobstetricians. A list was drawn up of all the obstetricians in eachunit who had at least five years’ experience in obstetrics andgynaecology. Clinicians who did not have a regular fixed labourward session were excluded from the list. The senior midwiveswere asked to rank the obstetricians. The criterion for ranking wasthat the obstetrician was competent and skilled at operativevaginal deliveries. The obstetricians who were consistently rankedhighly were invited to take part in the study. The expert midwiveswere defined as senior midwives who acted as coordinatingmidwives on labour ward and were ranked highly for theirexperience and expertise by the midwifery managers and the leadconsultant obstetrician for labour ward. All the invited expertsagreed to participate in the study.

By targeting expert participants we aimed to enhance thequantity and the quality of data. The data from expert obstetricianswere increased further because they had two observations each(recorded interview and video recordings). According to Morse[12], the greater the amounts of usable data that can be obtainedfrom one participant, the fewer participants are required. Havingpurposely sampled data-rich participants, we anticipated that asample size of ten obstetricians and ten midwives would be

required (thirty observations in total), with the plan to continuerecruitment till there was saturation of ideas and no new themesemerged. The saturation of ideas was reached with a total of tenobstetricians and eight senior midwives between the two centres.

The expert obstetricians and the senior midwives were invitedto a semi-structured interview. Each expert was given four clinicalscenarios, reflecting good and bad operative vaginal deliveries theyhad witnessed. The aim of these scenarios was to investigate howexperts use the clinical information provided to make decisionsregarding the mode of delivery, selection of the place for deliveryand choice of instrument. These scenarios depicted clinicalsituations with a range of complexity. The first scenario promptedthe investigation of decision-making for a low cavity non-rotational delivery and the strategies for avoiding operativevaginal deliveries. The scenarios sequentially increased in com-plexity and the final scenario investigated the decision-makingfactors regarding a mid-cavity rotational delivery and the option ofimmediate caesarean section without attempting an operativevaginal delivery.

The introduction to the scenario mirrored a typical casesummary given by a midwife when asking an obstetrician toreview a woman in the second stage of labour. Further informationregarding clinical findings was provided as requested by theexpert. In order to make their implicit knowledge and decision-making more explicit, the experts were asked to elaborate on theirdecisions by asking ‘how’ and ‘why’ at each decision point. Theexperts were also asked to discuss the common errors they havenoticed when supervising trainees, their recollection of a good anda poor delivery they had performed or witnessed, and the factorsthat had an impact on the outcome. When discussing errors inconducting operative vaginal deliveries, the experts were alsoasked the proposed actions they would consider to prevent theseerrors from occurring. Seeking senior help was considered a validaction for a trainee obstetrician. The expert obstetricians were thenvideo recorded conducting two operative vaginal deliveries (onevacuum, one forceps) in a simulation setting using the sameclinical scenarios. The videos and interview transcripts werereviewed by experts focussing on various decision points and thefactors considered when making those decisions.

The interviews were transcribed verbatim and analysed usingthematic coding. The Atlas.ti 5 computer package was used forcoding the data [13]. The anonymised data were individually codedby the three researchers and then compared for consistency ofinterpretation. The codes were categorised into themes based onthe decision points when considering an operative vaginaldelivery. The decision points were clearly apparent from theexpert interviews. The themes that emerged following the codingwere reviewed by the original experts for respondent validation.Data from all the experts were amalgamated to formulate a list ofclinical findings that would usually favour one instrument overanother. This list was peer reviewed and further validated by threesenior obstetricians outside the study regions, known for theirexpertise in intrapartum care and operative vaginal deliveries.Where there was discrepancy in the opinions of the experts, theopinion of the peer reviewers was taken into consideration toselect the most appropriate opinion. The study was approved bythe multi-centre regional ethics committee and the research anddevelopment departments at both units. Written consent wassought from each participant.

3. Results

In order to identify the steps taken in decision-making aroundoperative vaginal deliveries, the first step was to identify theinformation used to make the decisions. Cognitive task analysisinvolves identifying the resources needed and the cognitive skills

Table 1.1Significant information and its implications: review of notes and history.

Inf ormati on Meaning Acti on

Demographic de tails

Medic al hi story1. Diabetes Increased risk of s houlder dystocia Consider review by s enior ob stetrician

Consider deli very in theat re2. Risk of bleeding disorders of the fet us

Risk of trauma related intrac ranial hae morr hage Avoid diffic ult OVD * es pecial ly vac uum

3. Infections: Hepatitis B, C, HIV etc.

Risk of vertical transmission throu gh abrasi ons on fetal head

Avoid mid ca vity deli veryAvoid metal or Kiwi cupAccepta ble to conduct non rotat ional low ca vity deli very

Matern al BMI Increased risk of s houlder dystociaAbd ominal and vaginal asses sments may be more diffic ult

Consider review by s enior ob stetricianConsider deli very in theat re

Anten atal cour se1. Gestation: <34 weeks

34-36 weeks

>42 weeks

Risk of ce rebral hae morr hage wit h vac uum device

Cauti on with vac uum

Risk of placental insufficiency, dystocia

Vacuum deli very is contrai ndicate d

Vacuum deli very is relat ively contrai ndicated

Consider ea rly inte rventi on for patho logical CTG #

2. Suspected fetal growt h restricti on, reduce d liquo r volume, abno rmal dopple rs

Placental reser ve may be reduced, therefore greater risk of fetal intrapartum distress

Avoid prolonged sec ond sta ge

Partog ram1. Sponta neous / induce d labou r

Eff ect of oxytoci n use on fet us, ute rinehyperstimulation

Consider reducti on in rate of oxytoci n infusion

2. Contractions Inadequate contractions may redu ce chances of a spontaneous delivery

Consider ox ytoci n to enhance contracti ons

3. Anal gesia Need adequ ate pain relief for deli very Favour vac uum if there i s no epidural or the epidural is ineffecti ve

4. Pr ogres s from 8cm onwa rds Sl ow progres s may be su ggest ive of mal position / cephal o pel vic disproporti on

Consider review by senior ob stetrician

Bir th pl an Need to consider maternal preferences when making decision re OVD for maternal cooperation and satisfaction

Review maternal preferences in relation to pu shing, OVD, episiotom y and third sta ge management

* Operative vaginal delivery.

# Cardiotocograph.

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Table 1.2Significant information and its implications: examination.

Information Meaning Action

Maternal wellbeing1. Dehydration Dehydration will impair pushing Correct dehydration

2. Pyrexia ≥ 38o C Risk of chorioamnionitisMay reflect obstructed labour

Screen/Treat for sepsisConsider early recourse to OVD*Inform neonatology team at delivery

3. Maternal fatigue Reduced likelihood of spontaneous birth If woman agrees to carry on, encourage pushingChange maternal position

4. Hypertension in second stage Risk of seizures /stroke Shorten second stage by conducting an OVD

Fetal wellbeingUnsatisfactory intermittent auscultation Abnormal CTG, Meconium stained liquor, Low pH on FBS

Assess fetal condition to decide need to the expedite delivery and to select the delivery likely to be best tolerated by the fetus

Consider expediting deliveryConsider OVD vs Caesarean section

Abdominal palpation1. Estimate Fetal size: a. Large baby

b. .Small baby

Risk of shoulder dystocia

Placental reserve may be reduced, therefore greater risk of fetal intrapartum distress

Consider review by senior obstetricianConsider delivery in theatreConsider early recourse to OVD

1. Engagement: Head ≥ 2/5th palpable

1/5th palpable

Largest diameter of fetal head has not entered the pelvic inletGreater risk of borderline CPD#

OVD is contraindicated

Consider delivery in the operating theatre

4. Fetal back May be a useful indicator of fetal mal position Consider review by senior obstetricianConsider delivery in theatre

5. Palpable distended bladder May obstruct descent of fetal head Empty bladderVaginal examination1.Cervix not fully dilated OVD can lead to cervical laceration OVD contraindicated

2. Station above spines Head not engaged OVD contraindicated

3. Position: > 45o rotation from OA Mal position requiring rotational delivery Senior obstetrician should be present for the deliveryConsider delivery in theatre4. Station at spines +0 to +1 Mid cavity delivery suggesting biparietal diameter not

passed through the pelvic outlet5. Moderate/ severe caput Defining position can be challenging Consider review by senior obstetrician

5. Moderate/ severe moulding Possible CPD suggesting greater complexity6. Minimal movement of presenting part with maternal effort during contractions

Possible CPD suggesting greater complexity

7. Pelvic findings sub-optimal Possible CPD suggesting greater complexity

Consider review by senior obstetricianConsider delivery in theatre

Consider direct caesarean section

* Operative vaginal delivery.

# Cephalic pelvic disproportion.

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Assessment

Anticipate / encouragespontaneo us b irth

Operati ve delivery

Caesarean section Operative vag inal delive ry

Low cavity, no n rotati onal deli very Mid cavity deli very Non ro tatio nal / rotati onal

Choice of ve nue Choice of instr umentAim to deliver in lab our room

Fig. 1. Decision points when considering an instrumental delivery.

R. Bahl et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 333–340 337

required to process the information. The clinical scenarios thatwere given to the obstetricians did not give detailed clinicalfindings. This led the experts to process the information presentedand ask for relevant clinical information. This highlighted thefactors they used to analyse the clinical situation. Once the relevantclinical information had been obtained, the next step was to usethe information for value analysis in the given clinical scenario. Theexperts were encouraged to describe how the clinical findingsinfluenced their decisions. Tables 1.1 and 1.2 show the clinicalhistory and examination findings and their contribution to thedecision-making process.

Once the information had been gathered and assimilated, thenext step was to analyse the information used to make appropriatemanagement decisions. When making complex decisions, theclinicians often divide the task into subtasks and make a sequenceof decisions for each task. Therefore the experts were asked indetail about various decision points involved in managing a clinicalsituation where an operative vaginal delivery is likely to berequired. Fig. 1 shows the sequential decision points identified. Italso depicts the major themes identified during the analysis. Theminor themes, where significant, have been added to the relevant

If the CTG is normal and it is a primip pushing for only one hour, if she hapushing and talk to the mother, if she agree s let he r have the opt ion of push

- After one hour of pushing you are assessing for: Checking that the p exhausted that she cannot push? B1

-You may want to put up some syntoc inon if the contractions are not very g

Really encourage the mother, by somebody coming into the roo m and encoable to persuade her to push a lit tle bit longer…….Assess if she has got to tdeliver the baby. B6

If she has b een pushing for 1 hour and the vertex is visib le, one option is tospontaneous vaginal delivery…….If the head was crowning but held back she has passed urin e or whe the r it would be appropriate to cath eterise and e rega rding CTG and the contractio ns a re inadequate, consider putting up s yn

Discuss with the woman that if she is compl etely exhausted , I will offer an she may be ab le to have a spontaneous delivery. D7

If she is pushing adequately and th e CT G is fine, give her another half an h

Occasion ally you can manage a normal deliv ery by mak ing the m push a litD10

Fig. 2. Measures to improve chan

tables. When discussing the clinical scenario of an outlet operativevaginal delivery, we also investigated the strategies experts used toavoid operative vaginal delivery in order to allow spontaneousvaginal delivery. Fig. 2 shows the interview codes for the measuresto avoid operative vaginal delivery. These codes were analysed andled to formulation of strategies to avoid operative vaginal delivery(Fig. 3). Similarly when discussing the mid-cavity delivery, weinvestigated the factors that the experts considered when selectingbetween operative vaginal delivery and proceeding to immediatecaesarean section without a trial of instrumental delivery (Table 2).If the decision was made for operative vaginal delivery, factors thatwould prompt the experts to consider delivery in an operatingtheatre setting instead of a delivery room were discussed (Table 2).Finally, we investigated the factors affecting the choice ofinstrument (Table 3). Whilst it is clear that the operator shoulduse the instrument they are competent at using for specificcircumstances, the factors described in Table 3 guide clinicianswho are competent in the use of more than one instrument. Whenthe decision for a low-cavity non rotational delivery was made,factors affecting choice between vacuum-assisted delivery andforceps delivery were identified. For mid-cavity deliveries, the

s ene rgy to do so, she can continue to push. Assess descen t with ing for some mor e t ime (max imum two hours).osition is not abnormal, there is ongoing progres s, is the mother so

ood. B5

uragin g that she is doing really well and the baby is fine, you may be he stage where she is compl etely exhausted a nd is not going to

continu e pushing for another p eriod of time to se e if she can have a by the perineu m, it will be an option to offer episio tomy…..Check if mpty the bladder to allow delive ry……If there is no concern tocinon to augmen t the contractions D5

instrument al delivery. However, if she is able to push a little longer

our D8

tle bit longer if the baby is okay and you have the woman ’s consen t.

ces of spontaneous delivery.

Check if the f etal condition i s re assuring

Prepare for de livery

Yes

Are t he contractions adequate?

Consider oxyt ocin to augment co ntractio ns

Is the mother pushing effecti vel y?

Consider c han ging maternal positi on

Is the blad der empty? If not, catheterise the maternal bladder

Is the deli very of t he head being arrested by the

perineu m?

Consider a n ep isio tomy

Is the position a nd statio n of the fetal head fa vourable?

Once the a bove hav e b een considered, ac cor din g to materna l pr eferenc e,

continu e p ushing for a dur ation specified by th e obs tetrician

For f urt her as sessment

No

No

No

Yes

No

No

Yes

Powers

Passages

Passenger

Fig. 3. Strategies to improve spontaneous birth.

R. Bahl et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 333–340338

options of rotational forceps (Kiellands), rotational vacuumextractors (Kiwi and the metal cup) and manual rotation followedby direct traction forceps were explored.

4. Comments

In this study we have analysed the decision points employed byexpert obstetricians and have tabulated the factors they take intoconsideration when proceeding to operative vaginal delivery. Thishas led to identification of a sequence of decisions that need to bemade before reaching a conclusion regarding when an interventionis needed, where to perform the delivery and which instrument touse.

Table 2Mid cavity delivery: Choice of mode of delivery and the venue.

Assessment May be suitable for OVD in the

delivery room

Position More likely if less than 458 rotation

from OA position

Station Spines +2 or below

At spines or +1 station if all other

examination findings are favourabl

Moulding Nil/+

Caput Nil/+

Descent with contractions and pushing Good/Moderate

Ease of rotation of fetal head with

maternal pushing or vaginal examination

Easy rotation

Birth canal/

pelvic dimensions

Subjective perception of adequate

pelvic dimensions

Fetal status (pathological CTG, low pH) The choice of delivery method

depends on the operator expertise.

and safest for mother and baby.

– A senior obstetrician should decide on the venue for a rotational delivery or the opt

– Presence of antenatal and intrapartum risk factors should favour delivery in theatre.

Whilst most of the literature on operative vaginal deliveriesfocuses on the knowledge required for an obstetrician to make safeclinical decisions, we believe this is the first study that hasidentified the sequence of decisions made and the factors thatcontribute to these decisions. This is an attempt to unravel theimplicit expertise and knowledge of expert obstetricians andmidwives to aid trainee obstetricians’ understanding of decision-making around operative vaginal delivery. The spectrum ofdecision-making in obstetrics involves tasks with varying degreesof uncertainty. Some decisions such as avoiding high cavityoperative vaginal deliveries are relatively certain, but the choice ofinstrument involves a large number of variables includingobstetrician and maternal viewpoints. Some decisions are mainly

Consider OVD in theatre Consider caesarean section

More likely if greater than

458 rotation from OA position

–

e

At spines or +1 Above the spines (cs mandatory)

At spines or +1 if other findings

are unfavourable

+/++ +++

+/++ +++

Minimal None

Some rotation No rotation

Subjective perception of

sub-optimal pelvic dimensions

Subjective perception of inadequate

pelvic dimensions

Aim for delivery that is quickest

ion of proceeding directly to caesarean section.

Table 3Factors affecting the choice of instrument.

Non rotational low cavity delivery Mid-cavity rotational delivery

Favour vacuum if:

Absence of a working epidural

Presence of good expulsive efforts

Presence of good contractions

Absence of marked caput and moulding

The birth canal is roomy

Favour forceps if:

Presence of a dense epidural block

Absence of good expulsive efforts

Absence of good contractions

Marked caput and moulding

The birth canal is not roomy

Having judged that attempting vaginal delivery is suitable

the following factors influence the selection of a particular method

Select manual rotation if:

Presence of good analgesia

Descent of fetal head with maternal effort

On vaginal assessment a degree of rotational movement is possible

The birth canal is roomy

Absence of signs of true cephalopelvic disproportion

Select Kiellands if:

Presence of a dense regional block

Descent of fetal head with maternal effort

The birth canal is roomy

Absence of signs of true cephalopelvic disproportion

Select vacuum extraction (with metal posterior cup or Kiwi omnicup) if:

In the absence of a dense regional block

Presence of good maternal effort

Absence of significant amount of caput

� A method should only be used if the operator is adequately trained. The operator should use the instrument he or she prefers.

� Mother’s preferences should be taken in account when selecting an instrument.

� Vacuum delivery is contraindicated for gestational age less than 34 weeks and face presentation.

� Fetal status in itself should not determine the choice of instrument. There is no evidence that one instrument leads to quicker delivery than the other.

� For mid cavity non rotational delivery, preference is towards non rotational forceps. Vacuum device can be used if that is mother’s/obstetrician’s preferred instrument or

there is good descent with contraction and maternal effort.

R. Bahl et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 333–340 339

analytical based on robust evidence but in aspects that lack robustevidence, the decisions are more intuitive based on availableinformation, knowledge and wisdom. The methodology employedin this study is qualitative and the evidence influencing theexperts’ decision-making has not been scrutinised quantitatively.Whilst the experts work within the remits of evidence-basedguidelines and protocols, this study has aimed to identify andencapsulate the application of available evidence in individualclinical situations. The potential limitation of this study is thatwhilst common clinical scenarios of varying complexity have beeninvestigated for the purpose of this study, there are likely to besome clinical situations where the decision-making processdescribed in this study may not be applicable. We have identifiedthe decision-making process for scenarios commonly encounteredin the second stage of labour, and when the clinical situation isambiguous or has greater complexity, we recommend that a seniorobstetrician should be consulted.

Good problem-solving, sound judgement and effective deci-sion-making are considered amongst the highest attributes ofclinicians [14]. More recently the expertise of the clinician hasbeen taken into account when trying to analyse the decision-making process. It has been proposed that expert clinicians have abank of ‘‘illness scripts’’ consisting of a story-like narration of atypical case of the condition that can be used when confrontedwith a new case [15,16]. Decision-making involves two stages. Thefirst is the stage of problem recognition. The second stage is that ofvalues analysis where one chooses from a list of probabilities [17].Experienced practitioners are said to possess ‘‘scripts’’ which areelaborated networks of knowledge fitted to the regular tasks theyperform. For relatively novice practitioners, the mental represen-tation is that of a basic mechanism of a disease or skill. They are yetto develop the illness scripts or a bank of cases to refer to. Thesedifferences in approaches taken by experts and novices need to beconsidered when teaching and assessing clinical reasoning.

The decision-making processes become more challenging whenthe information is incomplete and the clinical situation highlyemotive [18,19]. Decision aids can be used to reduce the relativeeffort needed for making a decision. A study has shown that

training specifically in decision-making has improved the breadthof considerations included in the decision as well as the orderlinessof the strategies employed [20].

This detailed illustration of the decision-making process couldaid trainees’ understanding of when to intervene, where to deliverand the optimal choice of instrument for operative vaginaldeliveries in relation to clinical assessment in the second stageof labour. Further research is required to identify the impact ofdecision-making training on the outcome of operative vaginaldeliveries.

Funding

Rachna Bahl was supported by a Wellbeing of Women (WoW)Research Training Fellowship. Charitable Trustees of United BristolHospitals.

Conflict of interest

No conflict of interest.

Ethical approval

The study was approved by South-West Multicentre ResearchEthics Committee (ref no: 04/MRE06/61) on 10th February 2005.

Authors contributions

All three authors carried out the study design and thematiccoding. RB was responsible for data collection, analysis and draftedthe manuscript which was revised by all three authors.

Acknowledgements

We are grateful to the participants for their time and expertise.We are grateful to Dr. Aldo Vacca, Miss. Sara Patterson-Brown andDr. Tracey Johnston for reviewing the study findings and theirexpert comments.

R. Bahl et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 333–340340

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