Introduction

Global increases in rates of caesarean section show no sign of abating. The US National Center for Health Statistics reported that deliveries by caesarean section in 2001 had increased to almost a quarter, the highest level since 1989.^w1 A similar rate was observed in England, Wales, and Northern Ireland in 2000.1 The greatest increases and variation between institutions are seen among first time mothers with a singleton pregnancy at term and women who have had a previous caesarean section. The American College of Obstetrics and Gynecology has recommended training in instrumental delivery to control and reduce the rates of caesarean section.^w2

In the United States the rates of forceps delivery have decreased despite an increase in operative deliveries.^w3-w6 In the United Kingdom, the rates of instrumental vaginal delivery range between 10% and 15%1 ^w7; these have remained fairly constant, although there has been a change in preference of instrument. In the 1980s most instrumental vaginal deliveries were by forceps, but by 2000 this had decreased to under a half. Much of the decline has been attributed to an increasing preference for vacuum extraction or for caesarean section when complex vaginal delivery is anticipated.2 3 ^w8 Lively discussion in both the medical and the lay press has centred on morbidity associated with operative deliveries, the importance of maternal choice, and best clinical practice.4 ^{w9 w10} Most women still aim for spontaneous vaginal delivery. If complications do arise during labour it should be possible to offer women suitable alternatives and not solely caesarean …