to the editor: The final paragraph of this Cochrane Brief states that “If a vacuum device is unsuccessful, delivery with forceps can be attempted.” There is growing evidence that newborns who experience failed vacuum delivery followed by attempted forceps delivery, or failed vacuum delivery followed by failed forceps delivery followed by cesarean delivery, have significantly more scalp and intracranial injuries, as well as increased morbidity and mortality. The 2000 American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin no. 17¹ and a 2010 article in Obstetrics & Gynecology² both address this issue and discourage the application of serial vacuum and forceps. Likewise, the current Advanced Life Support in Obstetrics curriculum speaks strongly to this issue.³ If vacuum delivery fails, proceeding directly to cesarean delivery is recommended.

in reply: I appreciate Dr. Olden's reference to the ACOGs' position statement, which notes that “Although studies are limited, the weight of available evidence appears to be against attempting multiple efforts at operative vaginal delivery with different instruments, unless there is a compelling and justifiable reason.” ¹ The Advanced Life Support in Obstetrics curriculum follows this recommendation. However, the practice bulletin is based on an analysis of studies of outcomes for sequential operative vaginal delivery.² It does not discuss or compare the alternative, which is a cesarean delivery in the second stage of labor after failed vacuum delivery. Readers should be aware of the guidelines produced by the Royal College of Obstetricians and Gynaecologists in the United Kingdom: “The use of outlet/ low-cavity forceps following failed vacuum extraction may be judicious in avoiding a potentially complex caesarean section. Caesarean section in the second stage of labour is associated with an increased risk of major obstetric haemorrhage, prolonged hospital stay and admission of the baby to the special care baby unit compared with completed instrumental delivery.”³ Additionally, a 2004 guideline from the Society of Obstetricians and Gynaecologists of Canada explains that “A neonate delivered by 2 operative interventions (i.e., Caesarean section following a failed vacuum attempt or forceps attempt, or vacuum and forceps birth) is more likely to have a serious injury than one delivered by any one of these interventions alone. Indeed, a positive correlation exists between the number of operative interventions in the second stage of labour and the likelihood of death or intracranial injury.”⁴

editors' note: As Dr. Olden points out, Dr. Kripke's analysis of the limited data on outcomes of attempted forceps vaginal delivery, rather than immediate cesarean delivery, after failed vacuum extraction is not consistent with recommendations from ACOG or the ALSO curriculum sponsored by the AAFP. However, we feel that Dr. Kripke's view represents an alternative interpretation of the imperfect science surrounding the issue of sequential operative vaginal delivery. But, to avoid any confusion that Dr. Kripke's “Practice Pointers” might represent a conclusion from the Cochrane review, we have deleted the final sentence from the online version: “If a vacuum device is unsuccessful, delivery with forceps can be attempted.”