542 The cesarean delivery rate in the United Kingdom is currently 21%, 1 with much debate as to whether this is too high or too low. Similar debate occurs on a worldwide scale where there is great difficulty in balancing delivery- related deaths with economic constraints. 2 Cesarean de- livery in labor accounts for as much as 50% of all caesarean deliveries in the United Kingdom and warrants greater attention. 1 Women with arrested progress in the second stage of labor are faced with a choice between a potentially difficult instrument vaginal delivery or ce- sarean delivery at full dilatation, each with inherent risks. Obstetricians have strong views about the treatment of women with arrested progress in the second stage, which has so far limited randomized controlled trials that ad- dress this issue. The views of women who have operative delivery in the second stage of labor and their prefer- ences for future pregnancies have received little atten- tion to date. A recent review suggested that operative deliveries that involve rotation of >45 degrees were likely to be aban- doned in the future. 3 This has been reflected in a survey of obstetric fellows of the American College of Obstetri- cians and Gynaecologists, which showed that more than one half of these physicians have abandoned midcavity as- sisted vaginal delivery in favor of cesarean delivery. 4 Clearly, there are concerns about maternal and infant safety in relation to complex instrumental vaginal deliv- ery, but it is essential that treatment decisions are based on reliable data. We have reported previously that the early maternal and neonatal morbidity rates that associ- ated with complex operative deliveries in the second stage of labor. 5 Maternal morbidity and neonatal admis- sion for special care occurred more frequently after ce- sarean delivery, with an excess of neonatal trauma after instrumental vaginal delivery, which suggests that the op- timal choice of delivery is far from clear. The views of women who experience operative delivery in the second stage of labor are essential to our understanding of what is both safe and acceptable obstetric practice. A successful instrument vaginal delivery may increase the likelihood of an uncomplicated spontaneous vaginal delivery in a fu- ture pregnancy. 6 However, this would be of little rele- vance if women were not prepared to embark on a further pregnancy or to consider a future vaginal delivery after a previous traumatic birth experience. From St Michael’s Hospital, Southmead Hospital, and the Ninewells Hospital and Medical School. Supported in part by the Mother and Baby Trust (R. E. L.) and by Gor- don Tirrat and Peter Soothill. Received for publication April 2, 2002; revised August 26, 2002; ac- cepted September 28, 2002. Reprint requests: Deirdre Murphy, MD, Department of Obstetrics and Gynaecology, Tayside Institute of Child Health, Level 4, Ninewells Hos- pital and Medical School, Dundee DD1 9SY, UK. E-mail: d.j.mur- phy@dundee.ac.uk © 2003, Mosby, Inc. All rights reserved. 0002-9378/2003 $30.00 + 0 doi:10.1067/mob.2003.67 Cohort study of maternal views on future mode of delivery after operative delivery in the second stage of labor Deirdre J. Murphy, MD, and Rachel E. Liebling, MB Bristol and Dundee, United Kingdom OBJECTIVE: The purpose of this study was to assess maternal views on the future mode of delivery after either previous instrument vaginal delivery or cesarean delivery at full dilatation. STUDY DESIGN: We conducted a prospective cohort study of 393 women with term singleton cephalic preg- nancies. RESULTS: More than one half of the cohort intended to have a further pregnancy, with no significant differ- ences between the instrument vaginal delivery and caesarean delivery groups (51% vs 54% before dis- charge; adjusted odds ratio, 1.04; 95% CI, 0.2, 6.0), and there was little change in maternal views over time. Women were more likely to aim for a future vaginal delivery after an instrument vaginal delivery (79% vs 39% before discharge; adjusted odds ratio, 4.5; 95% CI, 2.2, 9.2), but the proportion decreased over time (68% vs 42% at 1 year; adjusted odds ratio, 3.6; 95% CI, 1.6, 8.1). There were no significant differences in preferred future mode of delivery for women who had a caesarean delivery after a failed instrument delivery and those who were delivered by immediate caesarean delivery. CONCLUSION: A high proportion of women who have had a previous difficult instrument vaginal delivery would still prefer vaginal delivery in a future pregnancy. (Am J Obstet Gynecol 2003;188:542-8.) Key words: Maternal views, operative delivery, future delivery