title: Decision-making in operative vaginal delivery: when to intervene, where to deliver and which instrument to use? Qualitative analysis of expert clinical practice.
abstract: 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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  This detailed illustration of the decision-making process could aid trainees' understanding of the approach to safe operative vaginal delivery, aiming to minimise morbidity.
authors.affiliation: St. Michael's Hospital, Bristol, United Kingdom. Electronic address: rachnabahl@hotmail.com.
authors.forename: Rachna
authors.initials: R
authors.lastname: Bahl
authors.forename: Deirdre J
authors.initials: DJ
authors.lastname: Murphy
authors.forename: Bryony
authors.initials: B
authors.lastname: Strachan
mesh_terms: D000465:Algorithms; D003657:Decision Making; D005113:Extraction, Obstetrical / Q000523:psychology*; D005260:Female; D006801:Humans; D011247:Pregnancy
keywords: Choice of instrument; Operative vaginal delivery; Place of birth; Qualitative study; Technical skill