Attilakos et al.1 have demonstrated that in their institution the practice of vacuum delivery will not be improved by the introduction of the OmniCup vacuum extractor. However, it may be premature to extrapolate their findings to other institutions. For example, their centre had a relatively high failure rate with ‘standard cups’ (21% during the study and 25% in previous audits).
Other investigators, concerned with similar failure rates, have concluded that inadequate operator training is a significant factor.2 In the present study, 93% of vacuum extractions were undertaken by senior house officers or registrars and only 7% by consultants. Since 65% of the procedures were midpelvic and 29% rotational, most such obstetrically complex deliveries must have been undertaken by registrars in training. Unless these doctors had participated in training programmes that included instruction in midpelvic and rotational vacuum techniques and been supervised by practitioners who had themselves been adequately trained, the reported failure rates were unsurprising.
One strategy that policy makers might institute to reduce the number of failures would be to avoid vacuum extraction in the potentially difficult obstetric cases and to consider other methods for delivery. Increasing the forceps rate, currently at 3–4%, is one option given that 57% of the failed vacuum attempts were subsequently completed with forceps, but the rate of failure is also likely to be high in midpelvic and rotational attempts at forceps delivery without intensive training and appropriate supervision of the operators. Alternatively, caesarean section, currently at 22% of all births, might rise.