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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 


Section 3 - Procedures

Vacuum extraction

Figure P-6 shows the essential components of the vacuum extractor.


Figure P-6

Vacuum extractor 


  • Review for conditions:

- vertex presentation;

- term fetus; 

- cervix fully dilated;

- head at least at 0 station or no more than 2/5 above symphysis pubis.

  • Check all connections and test the vacuum on a gloved hand.

  • Provide emotional support and encouragement. If necessary, use a pudendal block.

  • Assess the position of the fetal head by feeling the sagittal suture line and the fontanelles.

  • Identify the posterior fontanelle (Fig P-7).

Figure P-7

 Landmarks of the fetal skull


  • Apply the largest cup that will fit, with the center of the cup over the flexion point, 1 cm anterior to the posterior fontanelle. This placement will promote flexion, descent and
    autorotation with traction (Fig P-8).

Figure P-8

 Applying the Malmstrom cup



  • An episiotomy may be needed for proper placement at this time. If an episiotomy is not necessary for placement, delay the episiotomy until the head stretches the perineum or the perineum interferes with the axis of traction. This will avoid unnecessary blood loss.

  • Check the application. Ensure there is no maternal soft tissue (cervix or vagina) within the rim

  • With the pump, create a vacuum of 0.2 kg/cm2 negative pressure and check the application.

  • Increase the vacuum to 0.8 kg/cm2 and check the application.

  • After maximum negative pressure, start traction in the line of the pelvic axis and perpendicular to the cup. If the fetal head is tilted to one side or not flexed well, traction should be directed in a line that will try to correct the tilt or deflexion of the head (i.e. to one side or the other, not necessarily in the midline).

  • With each contraction, apply traction in a line perpendicular to the plane of the cup rim (Fig P-9). Wearing high-level disinfected gloves, place a finger on the scalp next to the cup during traction to assess potential slippage and descent of the vertex.

Figure P-9

 Applying traction


• Between contractions check:

- fetal heart rate;

- application of the cup.


  • Never use the cup to actively rotate the baby’s head. Rotation of the baby’s head will occur with traction.

  • The first pulls help to find the proper direction for pulling.

  • Do not continue to pull between contractions and expulsive efforts.

  • With progress, and in the absence of fetal distress, continue the “guiding” pulls for a maximum of 30 minutes.


  • Vacuum extraction failed if:

- The head does not advance with each pull;

- The fetus is undelivered after three pulls with no descent, or after 30 minutes;

- The cup slips off the head twice at the proper direction of pull with a maximum negative pressure.

  • Every application should be considered a trial of vacuum extraction. Do not persist if there is no descent with every pull.

  • If vacuum extraction fails, use vacuum extraction in combination with symphysiotomy (see below) or perform caesarean section.


  • Vacuum extraction may be used in combination with symphysiotomy in the following circumstances:

- the head is at least at -2 station or no more than 3/5 palpable above the symphysis pubis;

- caesarean section is not feasible or immediately available;

- the provider is experienced and proficient in symphysiotomy;

- vacuum extraction alone has failed or is expected to fail;

- there is no major degree of disproportion.


Complications usually result from not observing the conditions of application or from continuing efforts beyond the time limits stated above. 


  • Localized scalp oedema (artificial caput or chignon) under the vacuum cup is harmless and disappears in a few hours.

  • Cephalohaematoma requires observation and usually will clear in 3–4 weeks.

  • Scalp abrasions (common and harmless) and lacerations may occur. Clean and examine lacerations to determine if sutures are necessary. Necrosis is extremely rare.

  • Intracranial bleeding is extremely rare and requires immediate intensive neonatal care.


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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support


General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages



Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems


Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia


External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section


Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy


Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy



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