Clinical recommendation	Evidence rating	References
Operative vaginal delivery using a vacuum device can cause less maternal trauma than forceps, but it can increase the risk of neonatal cephalohematoma and retinal hemorrhage.	A	11
Vacuum-assisted vaginal delivery using a soft cup causes less neonatal scalp injury than traditional rigid cups, but it also has a higher failure rate.	A	19
In vacuum-assisted vaginal delivery, proper application and use of the vacuum device, including limiting application time to 20 minutes and three pulls, as well as avoiding multiple disengagements of the vacuum (or “pop-offs”), can minimize adverse events.	B	23, 27, 28
Episiotomy during an operative vaginal delivery is no longer recommended because it can increase the risk of perineal injury.	B	29
Operative vaginal delivery using both a vacuum device and forceps has been associated with worse neonatal outcomes than using a single instrument.	B	18, 30