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Sir,

The commentary by Oláh1 is timely in view of the unbridled enthusiasm with which vacuum delivery is performed, not always successfully and sometimes with serious adverse consequences for the infant2. I would like to make a few suggestions how I believe a significant improvement in the unwanted outcomes referred to by Oláh could be achieved.

1. Critically assess the evidence for and against vacuum delivery. Outcomes from even the best designed studies will only ever reflect the existing standard of practice yet, when a bad outcome is reported, the competence of the operator is rarely considered. In 1963, as a fourth year medical student, I attended the Mater Hospital's Annual Clinical Meeting in Brisbane over which Sir Norman Jeffcoate presided as the Visiting Edwin Tooth Professor. When asked to comment following a presentation about vacuum delivery, he proclaimed authoritatively ‘In my department the place of the ventouse is in the broom cupboard’. Naturally, no discussion ensued. For many years, my attitude towards the vacuum extractor was influenced by that remark. Sadly, I still hear similar unscientific and unsubstantiated statements made at clinical meetings and read them in recommended textbooks.

2. Use devices that incorporate Bird's ‘posterior’ design feature for OT and OP fetal positions. Dr Geoffrey Bird introduced a modification of Malmström's cup in 1976 that should have revolutionised the practice of vacuum delivery for the management of malpositions of the fetal head3. He demonstrated that, provided cup applications were flexing and median and axis traction was applied, autorotation and delivery of the infant will occur in greater than 90% of the extractions commenced when the position of the occiput is transverse or posterior.

3. Critically review the role of soft cups. In a letter written in 1992, Dr Tage Malmström reminisced ‘In 1952 VE was considered as a joke in obstetrics. And in 1957 with my dissertation on VE in obstetric practice it was condemned as of no value in obstetric practice’. When I asked his opinion of the soft cups, he replied ‘To hell with the silastic cup. It is wrong!!!’ Of course, the evidence clearly shows that Malmström was quite correct4. The soft cups are inefficient devices that have unacceptably high failure rates and they do not reduce the incidence of cephalhaematomas or subgaleal haemorrhages. Unless the use of soft cups is restricted to outlet and low occipito-anterior positions when the fetal caput is visible, the high failure rates and frequency of injuries reported with vacuum delivery will persist.

4. Re-emphasise training in the management of labour and operative delivery. Deficiencies in essential knowledge and technical skills are widespread and the full potential for successful and safe vacuum delivery is unlikely to be realised until corrective strategies are instituted. Furthermore, it must be appreciated by trainers and trainees that forceps and vacuum techniques are completely different and that expertise in one does not automatically transfer to the other.

5. Raise the priority of vacuum delivery at decision-making levels. Despite the abundant criticism and controversy that vacuum delivery attracts, little ‘air-time’ is given to this topic at national and international clinical meetings. Vacuum delivery was not mentioned in any of the published official programmes for the 2002 annual clinical meetings of the American College of Obstetricians and Gynecologists RCOG/RANZCOG Congress in Sydney and the 3rd World Congress of Controversies in Obstetrics and Gynecology in Washington.

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