OBJECTIVE:To perform a systematic review of the literature on the effect of simulation training of operative vaginal delivery on learner technique and knowledge, operator comfort, and patient-centered outcomes.DATA SOURCES:MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, ERIC, The Cochrane Library, and ClinicalTrials.gov were searched from inception through April 2017. The search criteria used MeSH terms ("simulation training," "high fidelity simulation training," "teaching," "obstetrical extraction," "obstetrical forceps," "vaginal delivery," "clinical competence," and "internship and residency").METHODS OF STUDY SELECTION:A total of 30,813 articles were reviewed for inclusion. Studies detailing operative vaginal delivery simulation using forceps or vacuums and reporting health care provider or patient outcomes were eligible.TABULATION, INTEGRATION, AND RESULTS:All studies were independently reviewed by two investigators for inclusion. Only eight articles assessed the effect of simulation on trainee skill and comfort or patient outcomes and were included. Four were pretest-posttest studies, two were cross-sectional studies, one was a case-control study, and one was a cohort study. No randomized trials were identified. Simulation was associated with improved forceps placement accuracy and generated force during extraction, as well as increased operator knowledge and comfort with operative vaginal delivery. Additionally, simulation had no association with forceps failure rates, but there was an association with decreased rates of maternal lacerations and neonatal injury. The quality of the included studies was assessed with the Medical Education Research Study Quality Instrument, with a median score of 9.75 (range 9.0-13.5), indicating low-to-moderate quality.CONCLUSION:The available evidence suggests that improved technique, comfort, knowledge, and patient outcomes are associated with operative vaginal delivery simulation, but additional studies are required to further characterize such benefits for both forceps and vacuum.SYSTEMATIC REVIEW REGISTRATION:PROSPERO, CRD42018087343.