Preterm Assisted Vaginal Births: Is Vacuum Extraction Safer Than We Thought?

OBGYN Clinical Update

New Evidence Challenges Traditional Teaching on Vacuum Use Before 34 Weeks

For decades, vacuum-assisted vaginal birth before 34 weeks’ gestation has been discouraged because of concerns regarding intraventricular hemorrhage (IVH), subgaleal hemorrhage, and other neonatal intracranial injuries. However, a new retrospective cohort study from a Canadian tertiary care center suggests that vacuum-assisted delivery may be a reasonable alternative to forceps in selected preterm births.

Study at a Glance

Publication: International Journal of Gynecology & Obstetrics, 2026

Design: Single-center retrospective cohort study (2014–2021)

Population: 5,095 assisted vaginal births, including 246 preterm births (<37 weeks)

Comparison: Vacuum-assisted vs forceps-assisted preterm vaginal births

Among the preterm deliveries:

• 171 were vacuum-assisted

• 75 were forceps-assisted

• 36 births occurred before 34 weeks’ gestation (18 vacuum, 18 forceps)

  
  

Key Findings

Neonatal Outcomes

The investigators found:

✅ Similar rates of neonatal head ultrasound screening between vacuum and forceps deliveries before 34 weeks (38.9% in both groups)

✅ Identical rates of Grade I IVH in infants delivered before 34 weeks (27.7% in both groups)

✅ No major intracranial or extracranial hemorrhages identified in either vacuum- or forceps-assisted births before 34 weeks

✅ Comparable rates of:

• Low 5-minute Apgar scores

• Neonatal resuscitation

• Shoulder dystocia

Importantly, no increase in serious neonatal morbidity was observed with vacuum use in this highly selected population.

Maternal Outcomes

Vacuum-assisted delivery was associated with significantly lower maternal morbidity compared with forceps:

Outcome

Adjusted Odds Ratio

Obstetric anal sphincter injury (OASI)

0.26

Episiotomy

0.16

These findings reinforce previous evidence that forceps delivery carries a greater risk of severe perineal trauma.

Why This Matters

When operative vaginal delivery is required in a preterm birth, clinicians often face a difficult choice:

• Forceps delivery may be technically challenging in cases of malposition or asynclitism.

• Cesarean delivery at full dilation can be associated with maternal hemorrhage, surgical trauma, and complications affecting future pregnancies.

• Current guidelines generally discourage vacuum extraction before 34 weeks despite limited contemporary comparative data.

This study provides additional evidence suggesting that carefully performed vacuum-assisted birth may not confer greater neonatal risk than forceps, while potentially reducing maternal pelvic floor injury.

Clinical Pearls

🔹 Vacuum-assisted delivery before 34 weeks remains controversial, but emerging evidence does not demonstrate increased rates of major neonatal intracranial hemorrhage compared with forceps.

🔹 Maternal outcomes may favor vacuum extraction, with lower rates of OASI and episiotomy.

🔹 Operator experience, fetal position, station, and individual clinical circumstances remain critical when selecting the mode of assisted delivery.

🔹 The findings support further prospective multicenter studies and registry-based research to better define safety thresholds and optimal patient selection.

Bottom Line

This study adds to a growing body of literature suggesting that vacuum-assisted vaginal birth before 34 weeks may be safer than traditionally believed. In selected cases where operative vaginal delivery is necessary, vacuum extraction may offer neonatal outcomes comparable to forceps while reducing maternal perineal trauma. Larger prospective studies are still needed before widespread changes to clinical guidelines can be recommended.

Reference

Leps C, Naseef P, Almoli E, et al. Preterm assisted vaginal births and associated maternal and neonatal outcomes: A retrospective study in a tertiary hospital. International Journal of Gynecology & Obstetrics, 2026. (Obstetrics & Gynecology⁠)

This summary is based on the study’s reported outcomes and conclusions.