Discussion.
This is a qualitative research study of factors affecting confidence and
competence amongst obstetricians in performing OVDs. Factors ranged from
the patient centred (respect for the primiparous OVD, fear of causing
harm) to personal (self-doubt, level of experience, gender), to team
(wish for senior midwifery support and teaching by consultants), to
training (forceps training, importance of experience).
Strengths and limitations
This study interviewed obstetricians with a wide range of experience and
both genders well represented. Obstetricians from three different units
were interviewed providing a wide view. Qualitative methods allowed
development of independent and novel themes that the researchers had not
considered prior to the study. Using an inductive approach – moving
from the data to a hypothesis – means that we can explore what people
really mean and how they really behave and why. A potential limitation
is that data will always be interpreted through the lens of the
researcher or research team, though this is limited by use of more than
one reviewer of data. The interviewer was an trainee so consultants may
have felt constrained during interviews; one of the main concerns for
all participants was social desirability bias – that participants would
answer questions in a manner to be viewed favourably by the
researcher23.
Interpretation
A strong theme emerging from all interviews was respect for the
primiparous OVD. Primiparity has been proven as a factor associated with
increased risk of failure of an OVD18, as well as an
increased risk of obstetric anal sphincter injury24,
therefore expression of unease by doctors is not surprising, and shows
respect for the procedure in this population.
A senior midwife who is supportive and has plenty of experience in
dealing with obstetric emergencies including OVDs was one of the most
commonly talked about factor that affected both confidence as well as
competence of trainees.
Midwives are the primary caregivers responsible for managing both low
and high-risk labour. Most women get one to one midwifery care during
labour and delivery. It is natural that the midwife providing one to one
care will have an intimate knowledge of parents and their wishes and can
advocate for them if required. A supportive and experienced midwife can
build a trustful relationship with the patient which is essential to a
positive birthing experience for mothers25. Therefore,
it’s not surprising that obstetricians rely on the midwife to help them to engage
with the woman and lack of midwifery support can lead to lower levels of
confidence.
Presence of a supportive consultant in house made trainees feel
confident and reassured. An unsupportive consultant was one of the
factors affecting trainees’ confidence and made them feel uncomfortable.
Unfortunately it has been shown26 that fear,
hierarchy, anger, and intimidation were key elements of trainees’
perception of relationship with trainers who oversaw their training in
the Irish medical system. Lack of support for doctors during training
may encourage efforts to hide uncertainties, and compromises training
and patient safety. If this is also true in Obstetrics and Gynaecology,
it is natural that fear and intimidation can bar obstetric trainees from
expressing concerns and insecurities to their consultant colleagues and
in turn compromise patient safety as well as potentially lead to
retaining bad habits and malpractices.
Trainees expressed the need for more direct supervision by consultant
obstetricians in the early years of training. Despite perceptions from
consultants that support was immediately available, senior trainees felt
that the newer generation of trainees is being supervised by near peers,
potentially compromising patient safety as well as trainee training. The
“see one, do one, and teach one ” approach is no longer
acceptable in medical practice especially when high risk care is
required, and invasive procedures are performed27. It
is therefore essential that trainees realise they have the opportunity
to observe consultant obstetricians or very senior trainees (HST4+)
performing operative vaginal deliveries, understand the mechanics of
labour and are exposed to simulation training as part of their
curriculum. This is not to suggest that more junior trainees cannot
provide peer to peer or peer to near peer input as this has been shown
be helpful in overcoming cognitive dissonance28 (where
more experienced clinicians have forgotten what they did not once know)
but in a supportive capacity during simulation rather than a supervisory
capacity during clinical work.
All trainees and consultants expressed their fear of causing harm to
mother or fetus. Consultants felt that the risk of complications and
psychological trauma was their major worry when performing an OVD. This
suggests that with increasing experience, clinicians became increasingly
aware of what could possibly go wrong and prepared accordingly. It is an
interesting findings that trainees did not mention emotional well-being
of the mother as one of their concerns which suggests the need for
formal training in the form of multidisciplinary obstetric drills to
enhance and teach the trainees the importance of good non-technical skills and that an operative vaginal delivery is
more than just delivering the baby vaginally8.
Trainees expressed the need for more training with the use of forceps.
Consistent with other studies6,7, junior trainees
expressed lower level of confidence with using forceps as a primary
instrument and showed high confidence level in using ventouse. Studies
have shown that teaching on mannequins or simulators leads to similar, and at times better, results when compared to training with human
subjects29. Simulation training in OVD has now become a standard part of training in both BST and HST curricula.
The general feeling expressed by most female trainees was of
nervousness, apprehension and self-doubt, whereas male trainees and all
consultants reported that they felt confident and comfortable with
performing operative vaginal deliveries. This theme is not unique to
this study. Female specialist trainees have self-perceived themselves to
be less competent in advanced emergency skills than their male
counterparts15 or that females underestimated their
level of performance on certain tasks when compared to
males30. Women may report31,32 more
negative opinions regarding their scientific abilities compared to men
despite performing equally in a science quiz, and their levels of
self-evaluation were less positive than men. This is an interesting
finding and could possibly be linked to what is described as the“Imposter phenomenon ”. Imposter phenomenon is mostly described
in the non-medical communities, but in medicine it reflects the feeling
of self-doubt expressed by doctors despite showing enough evidence of
competence33. Whether the feelings of self-doubt are
associated with imposter phenomenon or are a true reflection of a female
trainees’ limitations and abilities is beyond the scope of this study.
Self-doubt is usually exacerbated in conditions where confidence must be
shown but is not felt; performing an operative vaginal delivery demands
both confidence and competence, and this could explain the discrepancy
in trainees’ answers.