BJOG: an International Journal of Obstetrics and Gynaecology

March 2003, Vol. 110, pp. 319 –322

Unexpected reduction in the incidence of birth trauma and birth

asphyxia related to instrumental deliveries during the study
period: was this the Hawthorne effect?
W.C. Leung*, H.S.W. Lam, K.W. Lam, M. To, C.P. Lee
Objective The study was originally designed to identify the risk factors that could predict those difficult
instrumental deliveries resulting in birth trauma and birth asphyxia.
Design A prospective study on all singleton deliveries in cephalic presentation with an attempt of instrumental
delivery over a 12-month period (13 March 2000 to 12 March 2001).
Setting A local teaching hospital.
Sample Six hundred and seventy deliveries.
Methods A codesheet was designed to record the demographic data, characteristics of first and second stages
of labour and neonatal outcome. In particular, the doctor had to enter the pelvic examination findings before
the attempt of instrumental delivery.
Main outcome measures Birth trauma and birth asphyxia.
Results There was a significant reduction in the incidence of birth trauma and birth asphyxia related to
instrumental deliveries during the study period (0.6%) when compared with that (2.8%) in the pre-study
period (1998 and 1999) (RR 0.27, 95% CI 0.11 –0.70). There was more trial of instrumental deliveries in the
operating theatre although this was not statistically significant (RR 1.19, 95% CI 0.88 – 1.60). The
instrumental delivery rate decreased during the study period (RR 0.88, 95% CI 0.82 –0.94). The caesarean
section rate for no progress of labour, the incidence of direct second stage caesarean section and the
incidence of failed instrumental delivery did not increase during the study period.
Conclusions Apart from the merits of regular audit exercise and increasing experience of the staff, the
Hawthorne effect might be the major contributing factor in the reduction of birth trauma and birth asphyxia
related to instrumental deliveries during the study period.

INTRODUCTION examined the baby afterwards. Severe birth asphyxia refers

The true success of a trial of instrumental delivery is the
outcome, by whatever route, of the healthiest child and
mother. The true failure is not when vaginal delivery is not
achieved but when avoidable injury is inflicted1. Our
hospital is a local teaching hospital with about 4000
deliveries per year. There is a report system that every
single case of birth trauma (except cephalohaematoma and
clavicular fractures) and severe birth asphyxia would be
reviewed by a Birth Trauma Panel. The Panel consists of
two consultants, one associate professor and the chief
nursing officer of the labour ward. Birth trauma is ascer-
tained by the paediatrician who has attended the delivery or
Department of Obstetrics and Gynaecology, Queen Mary
Hospital, University of Hong Kong, China
* Correspondence: Dr W. C. Leung, Department of Obstetrics and
Gynaecology, Queen Mary Hospital, 102, Pokfulam Road, Hong Kong,
China.
D RCOG 2003 BJOG: an International Journal of Obstetrics and Gynaecology
doi:10.1016/S1470-0328(03)02948-3
to those cases with an Apgar score on the first minute of

3 requiring admission to neonatal intensive care unit.
There were altogether 30 cases of birth trauma and 13 cases
of birth asphyxia related to instrumental deliveries in 1998
and 1999 in our hospital (Table 1). The 13 cases of birth
asphyxia referred to those with the Birth Trauma Panel’s
conclusion that the instrumental delivery was contributing
to the asphyxia. The 30 cases of birth trauma included:
Erb’s palsy (10 cases); fractured skull (one case); fractured
skull with Erb’s palsy (one case); fractured skull with facial
nerve palsy (one case); fractured skull with subaponeurotic
haemorrhage (three cases); fractured skull with subapo-
neurotic and subdural haemorrhage (one case); fractured
skull with subaponeurotic and subarachnoid haemorrhage
(one case); subaponeurotic haemorrhage (six cases); sub-
aponeurotic and subarachnoid haemorrhage with facial nerve
palsy (one case); subarachnoid haemorrhage (one case); sub-
arachnoid haemorrhage with Erb’s palsy (one case); facial
nerve palsy (one case); facial laceration (one case); and lac-
eration of eyebrow (one case).
Our study was originally designed to identify the risk
factors that could predict those difficult instrumental
www.bjog-elsevier.com
320 W.C. LEUNG ET AL.

deliveries resulting in birth trauma and birth asphyxia. The RESULTS

ultimate goal is to reduce the incidence of birth trauma and
birth asphyxia related to instrumental deliveries. The
rationale is that if these difficult instrumental deliveries
can be predicted, one can then perform the instrumental
delivery in the operating theatre with full preparation for
caesarean section, or even to go ahead for a second stage
caesarean section directly.
METHODS
A prospective study was performed on all singleton
deliveries in cephalic presentation with an attempt of
instrumental deliveries in a local teaching hospital over
a 12-month period from 13 March 2000 to 12 March
2001. There are about 4000 deliveries each year. About
20% of them (800) are instrumental deliveries. The ratio
of vacuum extraction to low forceps deliveries is 3:1.
Majority of the instrumental deliveries are performed by
the residents who are undergoing the specialist training.
The rest of them are performed by specialists covering the
labour ward.
A codesheet (this form will be available on request from
the authors) was designed to record the demographic data,
characteristics of first and second stages of labour and
neonatal outcome. In particular, the doctor had to enter the
pelvic examination findings before the attempt of instru-
mental delivery. This is very important because retrospec-
tive entry of pelvic examination findings is often biased by
the outcome of the instrumental delivery. In order not to
cause any delay in the instrumental delivery, particularly in
case of fetal distress, the doctor did not have to write down
the pelvic examination findings himself or herself. For
every instrumental delivery, a midwife in the labour ward
would come up and ask the one who performed the delivery
about the pelvic examination findings (and record them on
the codesheet) before the actual attempt of the instrumental
delivery.
The research protocol was approved by the Hospital
Ethics Committee.
During the 12-month study period, there were only two
cases of birth trauma, subaponeurotic haemorrhage (one
case) and subarachnoid haemorrhage (one case), and
two cases of birth asphyxia with the Birth Trauma Panel’s
conclusion that the instrumental delivery was contributing
to the asphyxia. It was a significant reduction when
compared with that in the pre-study period (1998 and
1999) (RR 0.27, 95% CI 0.11 – 0.70) (Table 1). As there
were only four cases of birth trauma and birth asphyxia in
total during the study period, it would not be worthwhile or
appropriate to analyse the risk factors for these four
difficult instrumental deliveries. On the other hand, it
would be interesting to investigate why there was a sig-
nificant reduction in birth trauma and birth asphyxia related
to instrumental deliveries during the study period.
There was no change in the obstetric practice, staff
structure and coverage system of the labour ward as well
as the report system to the Birth Trauma Panel during the
study period when compared with that in the pre-study
period. Table 1 compared the instrumental delivery rate,
overall caesarean section rate and that for no progress of
labour, incidence of failed instrumental delivery, trial of
instrumental delivery in operating theatre and direct second
stage caesarean section during the study period with those
in the pre-study period. Relative risk with 95% confidence
interval was used to compare the various incidences using
the Instat software package. There was a significant
decrease in instrumental delivery rate during the study
period (RR 0.88, 95% CI 0.82– 0.94). The overall caesar-
ean section rate increased from 17.6% in the pre-study
period to 19.9% during the study period (RR 1.10, 95% CI
1.04– 1.17) but the caesarean section rate for no progress of
labour (including cephalopelvic disproportion, persistent
OT/OP position and uterine dysfunction) remained the
same. There was no significant difference in the incidence
of failed instrumental delivery and direct second stage
caesarean section between the study period and those in
the pre-study period. The incidence of trial of instrumental
delivery in the operating theatre increased during the study

Table 1. The hospital obstetric statistics in the pre-study period (1998 and 1999) and the study period (13 March 2000 to 12 March 2001).

Pre-study period (24 months) Study period (12 months) RR [95% CI]

Birth trauma and birth asphyxia related to instrumental deliveries* 43/1510 (2.8) 4/670 (0.6) 0.27 [0.11 – 0.70]
Instrumental delivery rate** 1494/7671 (19.5) 663/3996 (16.6) 0.88 [0.82 – 0.94]
Overall caesarean section rate** 1348/7671 (17.6) 795/3996 (19.9) 1.10 [1.04 – 1.17]
Caesarean section rate for no progress of labour** 268/7671 (3.5) 132/3996 (3.3) 0.96 [0.83 – 1.11]
Failed instrumental delivery* 16/1510 (1.1) 7/670 (1.0) 0.99 [0.53 – 1.84]
Trial of instrumental delivery in operating theatre* 51/1510 (3.4) 29/670 (4.3) 1.19 [0.88 – 1.60]
Direct second stage caesarean section*** 11/1521 (0.7) 3/673 (0.4) 0.70 [0.26 – 1.91]

* The denominator is the total number of attempts of instrumental deliveries. Values in parentheses are given as (%).
** The denominator is the total number of deliveries. Values in parentheses are given as (%).
*** The denominator is the total number of assisted deliveries in the second stage of labour, including direct second stage caesarean sections. Values in
parentheses are given as (%).

D RCOG 2003 Br J Obstet Gynaecol 110, pp. 319 – 322

 HAWTHORNE EFFECT IN THE REDUCTION OF BIRTH TRAUMA AND BIRTH ASPHYXIA
period when compared with that in the pre-study period,
although this did not reach statistical significance (RR 1.19,
95% CI 0.88 – 1.60).
DISCUSSION
The true success of a trial of instrumental delivery is the
outcome, by whatever route, of the healthiest child and
mother. The true failure is not when vaginal delivery is not
achieved but when avoidable injury is inflicted1. Vacuum
delivery is associated with greater neonatal morbidity and
mortality than was previously recognised, the adage that the
vacuum is designed to come off before infant damage occurs
appears unsubstantiated2. Out of the 43 cases of birth trauma
and birth asphyxia related to instrumental deliveries in the
pre-study period, 38 of them (88%) were by vacuum extrac-
tion. The majority of the instrumental deliveries resulting in
birth trauma and severe birth asphyxia occurred in the labour
ward (36/43 = 84%) when the difficulty was not anticipated.
If these difficult instrumental deliveries could be anticipated,
there was the possibility that earlier resort to caesarean
section or trial of instrumental delivery in the operating
theatre with full preparation to proceed to caesarean section
might reduce the incidence of birth trauma and birth
asphyxia. The neonatal and maternal morbidity from care-
fully conducted trial of instrumental delivery in the operating
theatre had been shown to be comparable to direct caesarean
section for prolonged second stage1,3. On the other hand,
birth trauma and severe birth asphyxia could still occur even
when difficulty was anticipated and trial of instrumental
delivery was already performed in the operating theatre
(7/43 ¼ 16%). One possible explanation was that if the
obstetrician was not willing to abandon the trial of instru-
mental delivery appropriately, the advantage of being able to
predict these difficult deliveries and to conduct the trial in
the operating theatre would be lost.
Contrary to our belief that these cases of birth trauma
and birth asphyxia are avoidable, Towner et al.4 showed
that the common risk factor for neonatal intracranial
haemorrhage is abnormal labour rather than the mode of
delivery. The significant reduction in the incidence of birth
trauma and birth asphyxia related to instrumental deliveries
during our study period did prove that they are avoidable.
Although there was only 1 out of the 43 cases of birth
trauma and birth asphyxia related to instrumental deliveries
in the pre-study period which had a long term sequel of
cerebral palsy, the short term sufferings to the neonates and
their parents in the other 42 cases could not be ignored.
The interesting question is what contributes to the sig-
nificant reduction in the incidence of birth trauma and birth
asphyxia related to instrumental deliveries during our study
period. There was no change in the obstetric practice, staff
structure and coverage system of the labour ward as well as
the report system to the Birth Trauma Panel during the study
period when compared with that in the pre-study period. The
D RCOG 2003 Br J Obstet Gynaecol 110, pp. 319 – 322
321
43 cases of difficult instrumental deliveries in the pre-study
period were not limited to those performed by a few
individual staff. Almost every specialist trainee and special-
ist who worked in the labour ward had their own share, with
their number of cases involved roughly proportional to the
total number of instrumental deliveries they had performed.
We do not think we can ignore the increasing experience of
the staff over the time as well as the merits of the Birth
Trauma Panel, which conducts regular audit exercises on all
the cases of birth trauma and severe birth asphyxia. But all
these are ongoing processes and we could not explain why
the reduction in the incidence of birth trauma and birth
asphyxia related to instrumental deliveries only occurred
when our study began.
We hypothesise the Hawthorne effect5 to be a major
contributing factor in the reduction of birth trauma and birth
asphyxia related to instrumental deliveries during the study
period. The Hawthorne effect refers to the tendency to
improve performance because of the awareness of being
studied. Furthermore, the design of our study is that the one
to perform the instrumental delivery has to enter the pelvic
examination findings before the actual attempt. Some of
these pelvic examination findings, in particular, the degree
of flexion of fetal head, the presence of asynclitism and the
descent of fetal head with maternal pushing were poorly
documented when we reviewed the records of the 43 cases of
difficult instrumental deliveries in the pre-study period.
Nevertheless, these pelvic examination findings before the
actual attempt of instrumental delivery might help to identify
those potentially difficult instrumental deliveries. This was
reflected by the increase in the incidence of trial of instru-
mental delivery in the operating theatre during the study
period although this did not reach statistical significance (RR
1.19, 95% CI 0.88 –1.60). Interestingly, when we presented
our study protocol in the hospital research meeting before the
study began, one of the colleagues did raise the question that
we might fail to identify the risk factors for these difficult
instrumental deliveries (the original objective of our study)
because of the Hawthorne effect. We did not think that
matters because the ultimate goal is to reduce the incidence
of birth trauma and birth asphyxia related to instrumental
deliveries, whatever the means to achieve this goal.
Did we perform more caesarean sections either before or
at the second stage of labour in order to avoid a difficult
instrumental delivery? Were we more often to abandon an
instrumental delivery and turn to a caesarean section in
order to avoid the potential birth trauma and birth asphyxia
related to a difficult instrumental delivery? The hospital
obstetric statistics told us that this was not the case
(Table 1). Although the overall caesarean section rate
increased from 17.6% in the pre-study period to 19.9%
during the study period but the caesarean section rate for no
progress of labour remained the same. There was also no
significant difference in the incidence of direct second
stage caesarean section and failed instrumental delivery
between the study period and those in the pre-study period.
322 W.C. LEUNG ET AL.
In fact the incidence of instrumental deliveries even
decreased in the study period (RR 0.88, 95% CI 0.82–
0.94). We postulate that the more careful and detailed
assessment in the second stage of labour (part of the
Hawthorne effect) had converted some of the unnecessary
instrumental deliveries into normal vaginal deliveries.
In conclusion, we hypothesise the Hawthorne effect to
be the major contributing factor in the reduction of the
incidence of birth trauma and birth asphyxia related to
instrumental deliveries during the study period. It is inter-
esting to observe how long would this Hawthorne effect
last after the study period. A well-designed randomised
controlled trial would be necessary to study the real impact
of this Hawthorne effect.
Acknowledgements
The authors would like to thank Ms Amy Chow of the
Information Technology Department, Hospital Authority,
HKSAR, for providing the hospital obstetric statistics and
the midwives in our labour ward who helped in the study.
References
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2. Ross MG, Fresquez M, El-Haddad MA. Impact of FDA advisory on
reported vacuum-assisted delivery and morbidity. J Matern Fetal Med
2000;9:321 – 326.
3. Revah A, Ezra Y, Farine D, Ritchie K. Failed trial of vacuum or
forceps — maternal and fetal outcome. Am J Obstet Gynecol 1997;
176:200 – 204.
4. Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode
of delivery in nulliparous women on neonatal intracranial injury. N Engl
J Med 1999;341:1709 – 1714.
5. Wickstrom G, Bendix T. The ‘Hawthorne effect’ — what did the orig-
inal Hawthorne studies actually show? Scand J Work Environ Health
2000;26:363 – 367.
Accepted 9 December 2002
D RCOG 2003 Br J Obstet Gynaecol 110, pp. 319 – 322