Should you use 2 types of obstetric (obstetric) vacuums for delivery?

Using Multiple Obstetric Vacuum Extractors for Delivery is Not Recommended

Using two types of obstetric vacuum extractors for delivery is strongly contraindicated due to the significant risk of fetal injury, including intracranial and subgaleal hemorrhage. 1, 2

Risks of Vacuum Extraction in Delivery

Vacuum extraction already carries inherent risks when used appropriately for vaginal delivery:

• Neonatal complications:

  • Subgaleal hemorrhage (most significant risk) 2
  • Intracranial hemorrhage 1, 2
  • Cephalohematoma and caput succedaneum 2, 3
  • Scalp injuries 3, 4

• Maternal complications:

  • Postpartum hemorrhage 2
  • Higher degrees of perineal tears 2

Vacuum Use During Cesarean Delivery

The American College of Obstetricians and Gynecologists explicitly warns against using vacuum extraction during cesarean delivery 1, 2. The 2024 guidelines on management of impacted fetal head at cesarean delivery specifically state:

• "The use of a vacuum at CD has the potential to cause significant fetal injury, such as intracranial and subgaleal hemorrhage" 1
• "A single forceps blade or ventouse, employed abdominally to assist delivery of an impacted fetal head at CD, is not recommended" 1

Vacuum Types and Their Appropriate Use

Different vacuum extractor types have different profiles:

• Rigid/metal cups:

  • More effective at achieving vaginal birth 4
  • Associated with higher rates of neonatal scalp trauma 3, 4
  • Lower detachment rates than soft cups 3

• Soft cups:

  • Cause fewer cosmetic effects and scalp lacerations 3
  • Higher failure rates than metal cups 4
  • Do not reduce incidence of cephalohematomas or subgaleal hemorrhage 3

• Hand-held vacuum:

  • More failures than metal vacuum 4
  • Slightly fewer failures than soft vacuum 4

Best Practice Recommendations

1. Choose a single appropriate vacuum device based on the clinical situation rather than using multiple types sequentially 1, 2, 3

2. Limit vacuum duration and avoid multiple cup detachments to reduce the risk of subgaleal hemorrhage 2

3. Consider alternatives when vacuum extraction fails:

   • If vacuum extraction fails, consider forceps or cesarean delivery rather than trying a second vacuum device 4, 5
   • Failed vacuum extraction followed by forceps (sequential instruments) carries additional risks 5

4. Ensure proper training:

   • Vacuum extraction should only be performed by properly trained clinicians who understand the risks and proper technique 2
   • Simulation training is recommended for difficult deliveries 1

Clinical Pitfalls to Avoid

• Do not attempt to use vacuum before complete cervical dilation as this is associated with higher failure rates 3
• Avoid incorrect cup application which can lead to detachment and failed extraction 3
• Do not persist with vacuum extraction when signs of difficulty are present (multiple detachments, lack of descent) 2, 3
• Never use vacuum extraction for cesarean delivery due to the high risk of fetal injury 1, 2

In conclusion, the evidence strongly supports using a single appropriate vacuum device when indicated for vaginal delivery, and completely avoiding vacuum use during cesarean delivery. Using multiple vacuum devices sequentially increases the risk of trauma without clear benefit.