Introduction and History
This article reviews the clinical use of vacuum extractor (VE) delivery instruments in modern obstetric management. The limitations and risks of the VE are considered, as is the choice of delivery technique (VE vs forceps vs cesarean delivery) when labor ceases or other complications ensue.
Both forceps and the VE are in use as delivery instruments. In recent decades, the VE has progressively replaced forceps as the instrument of choice for many practitioners.
Active controversy concerns if and when operative vaginal deliveries should be conducted and which instrument is the best to use in specific clinical settings.
VE has a long history. The initial applications of vacuum techniques in deliveries began in the 18th century. While VE became widely popular in Europe, the technique was little used in the United States until after the early 1980s, following the introduction of a series of new instruments, including disposable soft-cup extractors, new rigid cup designs, and handheld vacuum pumps.
Despite the current popularity of VE, forceps are the instrument of choice for many older clinicians. This is because of medical conservatism and original training, higher success rates, and a presumption of improved speed and control of the birth process. Nonetheless, VE has gained popularity as it is seemingly easy to use, requires less anesthesia/analgesia, has lower maternal morbidity, and is commonly believed to be safe. Large differences are observed in the popularity of instrumental delivery and of the specific type of instrument used in varying parts of the United States. This reflects the biases introduced by original training, the inherent conservatism of practitioners in embracing different techniques, and the absence of fixed guidelines for instrumentation.
The retirement of classically trained obstetricians, the inability to conduct training operations (which is now partially offset by new training models), the medical-legal climate, and other changes in practice (including the high incidence of cesarean deliveries) result in an unclear future for all types of instrumental delivery, including VE. Finding clear answers to important management questions concerning instrumental delivery remains elusive. A great deal of traditional lore concerning delivery practices remains. Objective analysis of what constitutes best practice by the newer methods of evidence-based medicine is limited by continuous changes in practice, small patient numbers in many studies, changes in the official definition of procedures, and, especially for VE, the introduction of new instruments.
Despite these limitations, a need still remains for safe and effective operative vaginal delivery options. Further, good data suggest that this help can be safely and expeditiously provided by an instrumental delivery using either the forceps or a VE instrument.
For related information, see Medscape’s Pregnancy Resource Center.