Letters.

Vacuum Extraction Issues

Dr. Julian Parer's comments regarding recommendations about vacuum extraction were timely and welcome ("Expert Offers Vacuum Extraction Strategies," Feb. 15, 2002, P. 8).

Dr. Parer's comments raise several issues about operative vaginal delivery (OVD). In this age of evidenced-based medicine, I am unaware of any studies evaluating fetal pain during OVD or during spontaneous delivery Is cesarean delivery less painful for the fetus than vaginal delivery?

I have never understood comments about maximum duration of vacuum application of no more than 15-20 minutes. Virtually all OVDs are done when the patient is in active labor. Since the patient is contracting regularly, the operator should accomplish the delivery within at least 10 minutes (given a maximum number of three pulls, as Dr. Parer and others suggest). This should certainly be the case if OVD is employed for a nonreassuring fetal heart pattern, -and most OVDs are completed within 5 minutes of instrument application.

Operator inexperience does play a role in vacuum pop-offs, but even in the hands of an expert, pop-offs can occur because of molding, caput medusa, and instrument malfunction. In that case, forceps can be used to complete a successful vaginal delivery and avert cesarean delivery I wonder what Dr. Parer's thoughts are about using vacuum or forceps to assist in delivery at the time of a C-section being done for a failed or unsuccessful OVD.

There is a medicolegal difference between an unsuccessful trial of OVD and a failed OVD. In the former, the operator is uncertain of the outcome and has therefore made preparations for immediate cesarean section if unsuccessful. In the latter, the operator is relatively certain of success and failure implies clinical misjudgment.

Dirk E. Peterson, M.D.