DOI: 10.1097/AOG.0000000000001232

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PMID: 26695571

Issn Print: 0029-7844

Publication Date: 2016/01/01


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Effect of Resident Participation on Outcomes in High-Order Cesarean Deliveries

Shigeki Matsubara; Akihide Ohkuchi; Alan K. Lefor

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Mourad et al1 showed that patients undergoing high-order cesarean deliveries performed by one resident and one attending obstetrician had no increase in adverse events compared with those performed by two attending obstetricians; they conclude that resident participation does not negatively affect outcomes. It is comforting to have evidence that supports our ethical responsibility to patients that resident participation does not have a negative effect. Although we all favor resident education in obstetric surgery, interpretation of these data requires caution.
Our strategy for resident education in Japan is “let the resident do it, and help at the moment.” If a resident nearly injures the uterine artery, the attending physician must intervene, covering the resident's limitations in technical skills. There are many technical aspects of high-order cesarean deliveries where attending physicians may intervene. Mourad et al1 state, “how much of the operation was actually performed by…the resident” was unclear. Thus, their data should be interpreted as: if the attending physician provided appropriate supervision, resident participation did not adversely affect outcomes. The age-old principle of graded responsibility must be respected when residents are operating.
High-order cesarean delivery is still challenging: severe intra-abdominal adhesions are one of the culprits. Adhesions tend to recur: their presence at one cesarean delivery strongly suggests they will occur at the next.2 As department chair, I (S.M.) always deploy two attending obstetricians if severe adhesions are expected. Experienced obstetricians may be able to anticipate a difficult cesarean delivery. Two attendings may have been deployed to difficult procedures in this study, as Mourad et al1 suggest. Thus, the data should be interpreted as: if higher risk deliveries were scheduled to be conducted by two attending obstetricians, resident participation did not adversely affect outcomes.
We agree that residents should be included in these complicated cases; resident education requires such training. However, inclusion does not always mean being the primary surgeon. Whether one resident and one attending is sufficient for every high-order cesarean delivery is doubtful. We envy Mourad et al's institution, which has competent supervisors and attending obstetricians—competent to the extent that resident participation did not affect outcomes in this difficult procedure.

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