Table 4.

CERQual assessments

Q1	SoF	Studies	CerQual assessment	Explanation of assessment
1	Non-technical skill expertise is essential to the optimal use of AVD. These skills include behavioural skills i.e. demonstrating capability through confidence, situational awareness, teamwork, communication, good relationships with the women and professional behaviour. Decision-making skills are also essential e.g. the appropriateness of AVD, if so, where to carry out the AVD (room or theatre), which instrument to use and when to abandon AVD	5 studies: Bahl 2010; Bahl 2013b; Simpson 2015; Alexander 2001; Sarangapani 2018 [17, 19, 21, 41, 43]	Low confidence	Due to low number of studies reporting on this finding
2	Broader clinical skills are essential to the optimal use of AVD. Clinical skills should encompass strategies that avoid AVD to optimise the opportunity for an SVD. Where AVD is clinically necessary, clinical skills include history taking, maternal and fetal observation information and abdominal palpation to include assessment of fetal descent into the pelvis. Skilled vaginal examinations that assessed fetal position, fetal station, fetal flexion, caput, moulding and engagement are essential. A minority suggest the skilled use of ultrasound to determine the fetal attributes prior to AVD Clinical skills should also include ensuring adequate analgesia for the women prior to AVD and the opportunity to debrief following the AVD	6 studies Bahl 2013b; Hodges 2015; Alexander 2001; Ramphul 2012; Sarangapani 2018; Simpson 2015 [16, 20, 34, 36, 40, 42]	Low confidence	Methodological concerns and limited data
3	Technical skills expertise is essential to optimal use of AVD. Technical skills expertise should encompass proficiency in rotating the fetus (manually or with forceps); appropriate timing of applying the instrument (between contractions); competence in the application of specific instruments; aptitude in the use of angle and consideration of the necessity of an episiotomy	3 studies Bahl 2008; Bahl 2013a; Simpson 2015 [17, 19, 42]	Low confidence	Due to low number of studies reporting on this finding

Q2	SoF	Studies
4	Proactive teaching, specific training and supervision are essential to achieving competence and expertise. Structured training and/or proactive teaching and supervision facilitates competence. Active tuition and close supervision throughout AVD by experienced colleagues skilled in teaching is particularly beneficial. This is influenced by the program (i.e. doctors training) expectations of learning AVD, thus providing the opportunities to achieve competency. Lack of teaching and/or specific training is a barrier to achieving competence in AVD	6 studies Evans 2009; Smith 1991; Simpson 2015; Hamza 2020; Hankins 1999; Healy and Laufe 1985 [28, 31–33, 42, 43]	Low confidence	Methodological concerns and limited data
5	Exposure to AVD including a range of instruments and the provision of opportunities to gain experience is essential to achieving competency and expertise. Competency development is facilitated by exposure and support with different instruments for AVD and different techniques required for varying clinical situations i.e. rotational forceps. Access to repeated opportunities to perform AVD was a key facilitator to developing the skill set to achieve competence. Conversely, a lack of exposure to gain experience, particularly in relation to forceps was a barrier to achieving competence and confidence	19 studies Bofill 1996a; Bofill 1996b; Healy and Laufe 1985; Rose 2019; Saunier 2015; Crosby 2017; Eichelberger 2015; Powell 2007; Sanchez del Heirro 2014; Smith 1991; Wilson and Casson 1990; Alexendar 2001; Al Watter 2017; Chinnock 2009; Fauveau 2009; Friedman 2020; Hamza 2020; Robson and Pridmore 1999; Sarangapani 2018 [15, 16, 22–25, 29–31, 33, 35, 37–41, 43, 45, 46]	Moderate confidence	Methodological concerns are mitigated by the number of studies that generated the SoF
6	The attitudes and beliefs evident in the training programme, work environment or individual practitioners appears to influence the attainment of competence and continued use of AVD. Preferences towards or against specific types of instruments appears to influence practitioner use which may in turn, influence attaining competence in and or all AVD options. In some situations, fears regarding litigation or through a lack of support staff influenced decision-making towards caesarean section over AVD	10 studies Bofill 1996a; Bofill 1996b; Hankins 1999; Devjee 2015; Eichelberger 2015; Powell 2007; Ramphul 2012, Robson and Pridmore 1999; Smith 1991; Wilson and Carson 1990 [23, 24, 27, 33, 36–38, 44, 46, 47]	Low confidence	Substantial methodological concerns regarding the survey studies

Q3	SoF	Studies
7	Access (or lack of) to training courses and/or willing clinical mentors influences the implementation of AVD training. Enabling facilitative environments include appropriate staffing usually by more experienced obstetricians who are skilled to teach AVD. This may be negatively influenced by clinical mentor’s preferences toward a particular instrument (forceps or vacuum), whereby trainees may not develop skills across all instrumental options. Training may also be impeded by a lack of teaching skills whereby articulating procedures and decision-making can be challenging	8 studies Devjee 2015; Powell 2007; Healy and Laufe 1985; Rose 2019; Wilson and Casson 1990; Sarangapani 2018; Bahl 2008; Al Watter 2017 [15, 17, 26, 33, 35, 38, 40, 45]	Low confidence	Methodological, adequacy concerns limit the confidence assessment

Q4	SoF	Studies
8	Access to training in AVD is sought after and valued by some practitioners. Some practitioners seek further and/or advanced training to develop their AVD skills citing the need to gain more experience and seek more supervision. Others (obstetric trainees, GPs on rotation and obstetricians) specifically reported additional training with forceps was necessary	6 studies Biringer 2019; Al Watter 2017; Devjee 2015; Bofill 1996b; Wilson and Casson 1990; Powell 2007 [15, 21, 23, 26, 35, 45]	Low confidence	Methodological, adequacy concerns limit the confidence assessment
9	Training enhances competence, confidence, job satisfaction and influences later clinical practice for some practitioners. For practitioners who were not obstetricians (medical officers, midwives) who were upskilled to manage emergency obstetrics, training enhanced feelings of competence in clinical and technical AVD skills. Furthermore, the training enhanced their confidence and increased their job satisfaction. For trainee doctors, not yet in a specialty, extra training including AVD influenced their decision to practise obstetrics. For obstetric trainees, access to specific AVD training enhanced their confidence and competence in AVD, particularly in the use of forceps	8 studies Evans 2009, Alexander 2001; Biringer 2019; Eichelberger 2015; Powell 2007; Al Watter 2017; Chinnock 2009; Smith 1991 [15, 16, 21, 24, 28, 35, 43, 46]	Low confidence	Methodological, coherence and adequacy concerns limit the confidence assessment
10	Practical teaching tools were valued by participants. Specifically designed training using a range of tools was reported to enhance participants learning. Videos and simulation training were viewed positively as formalised education to complement clinical learning	5 studies Sarangapani 2018; Al Watter 2017; Devjee 2015; Healy and Laufe 1985; Rose 2019 [15, 26, 33, 38, 40]	Low confidence	Methodological, adequacy concerns limit the confidence assessment

Bold values are the titles of the findings