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The effect of oestrogen supplementation on postmenopausal urinary stress incontinence: a double‐blind placebo‐controlled trial

Sic The cases of sub-aponeurotic haemorrhage reported by Fortune and Thomas (Vol 106, August 1999)’ serve as yet another caution for obstetricians from our paediatric colleagues of the serious neonatal injury that may be associated with vacuum extraction’. The current report is noteworthy not so much for the authors’ conclusions and recommendations but for the careful observations they recorded which provide a number of clues to indicate how three of the four cases of sub-aponeurotic haemorrhage may well have been prevented. The avoidable factors they describe include: 1. Incorrect (paramedian) vacuum cup applications: The chignon over the temporal region (Case 3) and the laceration over the parietal region (Case 4) describe incorrect applications. The use of a silicone cup in Case 1 where the position of the head was recorded as right occipito-transverse would also very likely have resulted in a paramedian cup application. 2. Detachment of the cup: Application could not be maintained in Case 1 and was very likely associated with the multiple failures in Case 3 and the cause of the laceration in Case 4. 3. Multiple instrumentation: In three of the four cases more than one instrument was used to complete the delivery after the initial attempt failed. 4. Incorrect diagnosis of the position of the fetal head: In Case 3 the temporal position of the chignon and bruising over the eyelid from the forceps despite an attempt at manual rotation suggests that rotation of the fetal head was greatly underestimated. 5 . Persistence after failure of the initial procedure: The cumulative effect of numerous tractions, manipulations and multiple instrumentations add up to excessive force being applied to the fetal scalps. 6. Late diagnosis of sub-aponeurotic haemorrhage: In one infant the haemorrhage was not diagnosed until 53 hours after the vacuum delivery. Some fluctuation of the scalp under the chignon is always present immediately after vacuum delivery in the infant whose scalp has been separated from the underlying cranium. The authors rightly point out that the benefits ascribed to soft cups over rigid cups in the Cochrane Library Review’ refer only to minor neonatal injuries and cosmetic effects. In fact, there is no evidence to suggest that soft cups, whether of the silicone or plastic variety, are likely to cause fewer sub-aponeurotic haemorrhages. On the other hand there are numerous reports of serious injury associated with all of the soft cup designs. For this reason, and in view of the higher reported failure rates of the soft cups’, their continued use and popularity should be seriously questioned. The authors also make the astute observation that use of the vacuum extractor must be weighed against the skill and judgement of the operator. Herein lies the most important clue for reducing the incidence of sub-aponeurotic haemorrhage and preventing mortality from this condition4. How many more infants must sustain the types of serious, yet largely avoidable, injuries described in this report before the warning signs are heeded?