The demise of vaginal operative obstetrics: a suggested plan for its revival.

Predictions made more than a quarter of a century ago regarding excessive use of cesarean delivery for cases of dystocia have been realized. Breech presentation, correctable dystocia, and twin gestation are increasingly being delivered by the abdominal route. Recent studies have shown that neonatal morbidity is not inherently improved by cesarean birth, and in fact have reported comparable results with vaginal operative procedures in properly selected and managed cases. Pressure to control the cesarean birth rate is now being exerted by consumer groups, professional groups, and governmental agencies. The reintroduction of vaginal operative procedures to modern obstetrics would help reduce the cesarean birth rate. However, major changes in the medical liability system, medical education and training, and the method of certifying obstetricians will be required before vaginal operative obstetrics becomes a serious alternative to cesarean delivery. Without these changes, I believe there is little hope of reversing the trend toward cesarean birth.