DOI: 10.1111/1471-0528.
13222
www.bjog.org
Traction force during vacuum extraction: a
prospective observational study
K Pettersson,a J Ajne,a K Yousaf,a D Sturm,b M Westgren,a G Ajnea
a
Department of Obstetrics and Gynaecology, The Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden b KTH Royal
Institute of Technology, School of Technology and Health, Stockholm, Sweden
Correspondence: G Ajne, Department of Obstetrics and Gynaecology, Karolinska University Hospital, K 57, Huddinge, S-14186 Stockholm,
Sweden. Email gunilla.ajne@karolinska.se
Accepted 15 October 2014. Published Online 5 January 2015.
Objective To investigate the traction force employed during
vacuum extractions.
Design Observational cross-sectional study.
Setting Obstetric Department, Karolinska University Hospital,
Sweden, and the Swedish National Congress of Obstetrics and
Gynaecology, 2013.
Population Two hundred women with vacuum extraction at term
and 130 obstetricians participating in a simulated setting.
Methods In a normal clinical setting, we used a specially adapted
device to measure and record the force used to undertake vacuum
extraction. In a subsequent part of the study, the force employed
for vacuum extraction by a group of obstetricians in a fictive
setting was estimated and objectively measured.
Main outcome measures Applied force during vacuum extraction
in relation to the estimated level of difficulty in the delivery;
perinatal diagnoses of asphyxia or head trauma; estimated force
compared with objectively measured force employed in the fictive
setting.
Please cite this paper as: Pettersson K, Ajne J, Youssaf K, Sturm D, Westgren M, Ajne G. Traction force during vacuum extraction: a prospective
observational study. BJOG 2015;122:1809–1816.
Introduction
Vacuum extraction is often chosen as an alternative to
obstetric forceps for expediting a vaginal delivery because it
is easy to perform and is associated with less extensive
maternal perineal damage.1,2 However, the prevalence of
neonatal complications such as asphyxia, intracranial haem-
orrhage3–6 and seizures7 is higher compared with that
observed with a spontaneous vaginal delivery.5 Whether
this is caused by the actual application of the instrument
or by the prolonged intrauterine forces exerted on the fetus
preceding the operative assistance is still debatable because
a similar increase rate is also observed with caesarean sec-
tions.5 Caesarean section also carries with it additional
ª 2015 Royal College of Obstetricians and Gynaecologists
Intrapartum care
Results The median (minimum–maximum) peak forces for
minimum, average and excessive vacuum extraction in the clinical
setting were 176 N (5–360 N), 225 N (115–436 N), and 241 N
(164–452 N), respectively. In 34% of cases a force in excess of
216 N was employed. There was no correlation between the
umbilical arterial pH at delivery and the traction force employed
during extraction. Four cases of mild hypoxic ischaemic
encephalopathy were observed, three of which were associated
with a delivery whereby excessive traction force was employed
during the vacuum extraction. In the fictive setting, the actual
exerted force was twice the quantitative estimation. The measured
forces in the clinical setting were four times higher than that
estimated in the fictive setting.
Conclusions Higher than expected levels of traction force were
used for vacuum extraction delivery. As obstetricians tend to
underestimate the force applied during vacuum extraction,
objective measurement with instantaneous feedback may be
valuable in raising awareness.
Keywords Failed vacuum extraction, traction force, vacuum
extraction.
potential maternal risks such as excessive haemorrhage,
uterine tears8 and sepsis.9 Prolonged labour also increases
the risk of postpartum haemorrhage.8 Failed vacuum
extraction (i e when a sequential method of delivery is
required) is associated with significantly higher risk of peri-
natal morbidity compared with spontaneous delivery or
successful vacuum extraction.6,10,11 O’Mahony et al.12 sug-
gested that this increase in adverse outcome of vacuum
extraction can be largely explained by poor clinical judge-
ment by the obstetrician.
Safety measures recommended for vacuum extraction
delivery include restricting the total time of the procedure
and the number of traction pulls, employing vacuum
extraction delivery for pregnancies beyond 34 weeks of
1809
 Pettersson et al.
gestation, and using the procedure only when the station
of the fetal vertex is at or below the ischial spines.13 An
additional piece of advice is to avoid excessive traction
force. All of these measures for safe vacuum extraction
deliveries can be achieved with training except for the
amount of traction force employed; the difference between
excessive, average or minimum traction forces employed
during the vacuum extraction is usually determined subjec-
tively by the obstetrician. There is little information regard-
ing the traction force employed during vacuum extraction
deliveries, but a few studies measuring this force using a
rigid plastic device with an internal meter have been
reported.14,15
The aims of the present study were to investigate the
actual traction forces employed for vacuum extraction in a
university hospital and to analyse the correlation between
the applied force and clinical outcome. We also sought to
determine whether the subjective assessment of the traction
force (minimum, average or excessive) estimated by the
obstetricians during a vacuum extraction in a fictive setting
correlated with the objectively measured force.
Methods
The first part of this study was undertaken from August
2012 to October 2013 at Karolinska University Hospital. A
total of 438 vacuum extraction deliveries were performed
during this period. This was 9% of all deliveries at the hos-
pital, which is similar to the Swedish national rate.16 All
singleton pregnancies resulting in a vacuum extraction
delivery were eligible for inclusion into the study, including
failed vacuum extraction, and the standards of the Royal
College of Obstetricians and Gynaecologists in the UK were
used to classify the extractions.13 All obstetricians were
encouraged to use the Bird metal cup that is attached to
the traction force measurement device described below.
However, a large proportion of the outlet vacuum extrac-
tion procedures were excluded from the study because
some obstetricians preferred to employ the plastic cups
instead for such deliveries.
The main outcome measures were the peak force and
the total force related to three categories of vacuum extrac-
tions. These categories have been used in the Swedish
maternity system since 1992 and represent the obstetrician’s
subjective perception of the traction force employed: mini-
mum, average or excessive. The forces used in successful
and failed vacuum extractions were also compared. Second-
ary outcomes were the neonatal umbilical blood gases, Ap-
gar scores and birthweight, and diagnoses at the neonatal
intensive care unit (birth asphyxia with pH in the umbilical
artery <7.1, cephalic haematoma, hypoxic ischaemic
encephalopathy and intracranial haemorrhage including
subgalealic haematoma). Descriptive and explanatory data
1810
from computerised maternal and neonatal medical notes
were collected and shown in Table 1.
To measure the traction force employed during vacuum
extraction, we used an intelligent handle hooked to the
chain of a regular metal cup (Bird 50 mm, 80 kPa) (Fig-
ure 1). The centre of the handle contains a force sensor
that accurately measures the force applied between the han-
dle and the hook of the metal cup. The signal is amplified,
converted to a digital format, processed by a micro con-
troller, and sent to a receiver. A computer program visua-
lises the parameters on an electronic tablet and this was
concealed from the obstetricians during the vacuum extrac-
tion. For the data analysis, the recorded information for
the vacuum extraction was stored in MATLAB (Math-
Works, Natick, MA, USA) and used to create a force curve
by plotting the recorded traction force (on the y-axis)
against the time (on the x-axis). Parameters such as the
peak traction force, the total traction force and the number
of pulls employed during the vacuum extraction were com-
puted from the force curve. The peak force is the highest
traction force (Newtons; N) recorded during the delivery.
The total traction force in Newton minutes (N minutes) is
the area under the force curve.
To determine if the pull-force profile (the comparison of
traction force between individual pulls) differed between
failed vacuum extraction, excessive successful vacuum
extraction, and the average plus minimum successful vac-
uum extraction, the peak traction force from the second
pull onwards was calculated as a percentage of the initial
pull.
In the second part of this study, a fictive setting was
used to assess the obstetricians’ estimates of their applied
traction force. One hundred and thirty participants (78%
consultants and 22% residents) were invited to participate
during a national conference of the Swedish Society of
Obstetrics and Gynaecology in September 2013. Using the
same handle described above, the participants were asked
to pull on a securely fastened string employing the traction
force they would employ during a clinical minimum, aver-
age and excessive vacuum extraction delivery. The order of
the three pulls was randomised for each participant. A
force curve was plotted in MATLAB using the recorded
data in the fictive setting. Here the peak traction force was
achieved almost instantly at the beginning of each pull and
lasted for the full 10 seconds. This created a table-shaped
force curve as opposed to the more bell-shaped force curve
observed in the real clinical settings. The traction force for
each category of pull (minimum, average or excessive) was
determined by averaging the force values at four points at
the top plateau of the table-shaped curved. As there was
insignificant variation in the traction force values at the
top plateau, the average and peak values for each plateau
were found to be essentially the same. The traction force
ª 2015 Royal College of Obstetricians and Gynaecologists
 Traction force during vacuum extraction

Table 1. Maternal, obstetrical and fetal characteristics

Group A Group B Group C P-value***

Minimum vacuum Average vacuum Excessive vacuum
extraction extraction extraction

Number, n* 114 37 42
Age, year** 30.6  5 30.6  5 31.6  6
Primiparous, n (%) 88 (77) 31 (84) 34 (83)
BMI, kg/m2** 24  4 25  4 25  5
Gestation, days** 277  10 279  9 283  7 <0.01a
Indication for vacuum extraction, n (%)
Asphyxia 49 (43) 17 (46) 15 (37)
Dystocia 64 (56) 20 (54) 27 (66)
Time from cervical dilatation at 3 cm 535  237 540  253 687  265 <0.05a
to fully dilated, minutes**
Time from fully dilated cervix to vacuum 160  86 185  77 173  80
extraction, minutes**
Time during vacuum extraction, median 6 (1–14) 10 (3–26) 11 (2–24) <0.01a,b
minutes (min–max)
Number of pulls, median (min–max) 3 (1–7) 5 (2–7) 5 (2–10) <0.01a,b
Station of fetal head
Mid cavity, n (%) 22 (19) 25 (67) 28 (68) <0.01a,b
Low cavity, n (%) 58 (51) 12 (32) 13 (32) <0.01a,b
Outlet, n (%) 31 (27) 1 (1) 0 <0.01b
Position of fetal head, n (%)
Occiput anterior 105 (92) 30 (81) 31 (76)
Occiput posterior 8 (7) 7 (19) 9 (22)
Fetal weight, g** 3500  466 3681  370 3796  428 <0.01a
Umbilical artery pH** 7.22  0.09 7.17  0.12 7.22  0.10

*Seven vacuum extractions were not categorized by the obstetrician.

**Mean  SD.
***aA versus C, bA versus B.

traction force and actual applied force. These traction

forces were correlated to the body mass index, gender and
professional seniority of the participants.

Figure 1. Illustration of the technical device.
therefore calculated for the fictive setting is comparable to
the peak force calculated for the clinical part of this study.
The participants were asked to estimate the traction
force (N) or weight (kg) that they estimated was applied
for each of the three pulls. Furthermore, they were asked
to declare any knowledge they had of an upper limit for
safe traction force during vacuum extraction. The primary
outcomes in this part of the study were the estimated
Statistical analyses
Descriptive statistics are presented as mean  SD or med-
ian (min–max) as appropriate. The primary analyses on
traction forces employed during vacuum extraction were
performed according to three groups: minimum, average
and excessive vacuum extraction. The traction forces
employed for failed and successful vacuum extractions were
also compared. The Mann–Whitney U-test, Kruskal–Wallis,
analysis of variance by ranks, and the Wilcoxon paired test
were used for data with a skewed distribution. The Wilco-
xon paired test was also corrected for multiple compari-
sons. The Student’s t-test was used to compare means in
normally distributed data. The chi-square test was used for
dichotomous data. A value of P < 0.05 was considered
statistically significant. All analyses were performed with
STATISTICA (StatSoft Inc, Tulsa, OK, USA).

ª 2015 Royal College of Obstetricians and Gynaecologists 1811

 Pettersson et al.
Results
A total of 46 consultants and residents performed the 200
vacuum extractions included in this study. These vacuum
extractions consisted of 77 mid-cavity, 86 low-cavity and 37
outlet extractions. This represented 69% of the mid and low
vacuum extractions and 21% of the outlet vacuum extrac-
tions performed at the hospital during the study period. Of
the 200 vacuum extractions, the majority were categorised
as employing minimum force (59%), whereas the average
and excessive force categories amounted to 19% and 22%,
respectively. Minimum traction forces were more com-
monly employed for low-cavity and outlet vacuum extrac-
tions whereas mid-cavity deliveries were more commonly
associated with the use of average and excessive traction
forces. Additional clinical data are shown in Table 1.
The measured peak and total traction forces are shown
in Table 2. The measured mean traction forces were high-
est in the excessive vacuum extractions and lowest in the
minimum category. However, there was a notable overlap
between these three groups, as well as large variation within
groups; the traction force employed varied up to 70-fold
from one participant to another for the minimum category,
and four-fold and three-fold for average and excessive cate-
gories respectively.
A significant increase in peak traction force was noted in
primiparous, 209 N (63–452 N), versus multiparous
women, 177 N (5–376 N) (P < 0.05), although the total
traction force employed did not differ between them. The
total traction force used in cases of occiput posterior posi-
tion, 355 N minutes (61 N seconds to 857 N minutes) was
significantly greater than the total force employed in cases
Table 2. Peak and total traction force employed for vacuum
extraction (n = 200)
A B C P-
Minimum Average Excessive
extraction extraction extraction
Peak 176 (5–360) 225 (115–436) 241 (164–452)
traction
force, N
Total 127 (0.7–511) 294 (64–857) 506 (160–1380)
traction
force,
N
minutes
P < 0.001 with Kruskal–Wallis analysis of variance by ranks for peak
force and total force.
Data shown are median (range).
*aA versus B, bA versus C, cB versus C (a,b,cMann–Whitney U-test).
1812
of occiput anterior position, 191 N minutes (0.7 N seconds
to 889 N minutes) (P < 0.05). The total time for vacuum
extraction did not differ between cases of occipital poster-
ior and anterior positions, but there was an increased num-
ber of traction pulls required for occipital posterior
position extractions compared with those for occipital
anterior positions, four (two to eight) pulls versus three
(one to ten) pulls, respectively (P < 0.05). Occipital poster-
ior position was also more commonly associated with
excessive vacuum extractions (including failed vacuum
extractions) compared with the average and minimum vac-
uum extraction categories (22% versus 10%, respectively,
P < 0.05).
There were no differences in peak or total traction force
in relation to medical indication for the vacuum extraction
or professional experience of the participant. No correla-
tion was found between the traction force employed and
the maternal body mass index, fetal weight, duration of
first or second stage of labour, umbilical artery pH or birth
asphyxia.
The proportion of birth asphyxia was similar in excessive
and non-excessive vacuum extraction (14% versus 15%
respectively), whereas cephalic haematomas were most
common in the minimum category. Four cases of hypoxic
ischaemic encephalopathy were diagnosed, three of which
occurred during excessive vacuum extraction. No cases of
severe hypoxic ischaemic encephalopathy or intracranial
haemorrhage were found.
Significantly higher levels of total traction force were
employed in cases of failed vacuum extractions when com-
pared with successful cases (Table 3). All failed vacuum
extractions were categorised as excessive. There was no dif-
ference in total procedure time or number of traction pulls
employed between failed and successful vacuum extrac-
tions. Fetal weight, gestational age and duration of the first
stage of labour were all significantly higher in failed vac-
uum extractions (Table 3).
The same comparisons were made between successful
value*
excessive and failed vacuum extractions (Table 3). Higher
peak and total traction forces, including increased time for
extraction and number of pulls, were employed with exces-
<0.01a
<0.001b sive successful vacuum extractions compared with failed
extractions. Fetal weight was higher and pH in the umbili-
<0.001a cal artery was significantly lower in those cases with a failed
<0.001b vacuum extraction.
<0.01c
The traction force profiles showed a significant continu-
ous decrease in force employed with each subsequent pull
compared with the initial pull. The decrease of force for
each pull was significantly greater in the average and mini-
mum vacuum extractions compared with those with exces-
sive vacuum extractions (Figure 2). In the cases of failed
vacuum extraction, the reduction of traction force was not
ª 2015 Royal College of Obstetricians and Gynaecologists
 Traction force during vacuum extraction

Table 3. Comparison between successful and failed vacuum extractions

Group A Successful A versus B Group B Failed B versus C Group C Successful

vacuum extraction vacuum extraction excessive vacuum
extraction

Number (n) 182 18 24

Gestation, days* 280 (252–294) <0.01 287 (280–294) NS 283 (259–294)
Time from cervical dilatation at 546  240 <0.01 774  263 NS 618  254
3 cm to fully dilated, min (mean  SD)
Station of fetal head, n (%)
Mid cavity (n) 61 (34) <0.01 16 (89) NS 15 (68)
Low cavity (n) 84 (46) <0.01 2 (11) NS 7 (32)
Outlet (n) 33 (18) 0 NS 0
Peak force, N* 200 (5–452) NS 224 (164–316) <0.05 250 (192–452)
Total force, N minutes* 260 (0.7–857) <0.001 391 (160–889) <0.01 595 (251–855)
Time extraction, minutes* 7 (1–26) NS 6 (2–17) <0.001 12 (5–24)
Number of pulls* 3 (1–10) NS 3 (2–6) <0.001 6 (4–10)
Position of fetal head, n (%)
Occiput anterior 160 (88) NS 13 (72) NS 18 (82)
Occiput posterior 22 (12) NS 3 (17) NS 6 (27)
Fetal weight, g (mean  SD) 3558  430 <0.01 3962  489 <0.05 3663  239
Umbilical artery pH (mean  SD) 7.21  0.11 NS 7.18  0.08 <0.01 7.26  0.10
Birth asphyxia, pH <7.10, n (%) 21 (12) NS 4 (22) NS 2 (9)
Shoulder dystocia, n (%) 5 (3) 0 2 (9)

*Median (range).

(A) (B)

Figure 3. Force (Newtons) in estimated pulls (A) and actually measured

Figure 2. Pull force profile, pulls numbers 2–5, percentage force with
respect to pull number 1 within each included vaginal extraction.
Means  95% CI of means; analysis of variance with repeated
measurements, P < 0.05 within each group, P < 0.05 between groups
at each pull; Student’s t test.
different to those with successful excessive extractions (data
not shown).
The estimated and actually employed traction forces for
vacuum extraction in the fictive setting are shown in
Figure 3. In the fictive setting, the exerted traction forces
in simulated pulls (B) categorised as minimum, average or excessive
among 130 clinicians (study part 2). P < 0.001 within group and
between, Wilcoxon corrected for multiple comparisons.
were about 50–100% greater than the estimated forces. The
traction forces in the actual clinical setting were about
150–300% greater than the estimated traction forces
employed in the fictive setting (Figure 4). Three of the 130
participants in the fictive setting claimed to know a recom-
mended maximum limit of the traction force to be used
for vacuum extractions. There was no correlation between
the traction force employed and the body mass index,
gender and professional experience of the participants.

ª 2015 Royal College of Obstetricians and Gynaecologists 1813

 Pettersson et al.
Figure 4. Graphic illustrations showing the differences in forces
(Newtons) between estimated (study part 2), simulated (fictive pull,
study part 2) and clinical extractions (study part 1).
Discussion
Main findings
The level of traction force employed during vacuum extrac-
tion in this study is generally higher than those reported by
earlier studies.14,15 There was no clear correlation between
the perinatal morbidity and the magnitude of traction force
employed during vacuum extraction; most cases of (mild)
hypoxic ischaemic encephalopathy were diagnosed after
excessive vacuum extraction, but neither cephalic haema-
toma nor birth asphyxia occurred more often after exces-
sive extraction.
The results from the fictive setting indicate that obstetri-
cians tend to underestimate the actual traction force
employed during vacuum extraction. Only three out of 130
clinicians claimed to be aware of a maximum limit of the
traction force to be used during vacuum extractions.
Strengths and limitations
This is an observational study with a study design to
describe traction forces employed for vacuum extractions
rather than to reveal any causal relationships. Hence, the
correlations observed between the traction force and any
clinical outcomes must be interpreted with caution. The
size of the study population is not sufficient to calculate
the level of traction forces during a vacuum extraction that
would result in the most severe perinatal outcomes such as
intracranial haemorrhage. On the other hand, the force
sensor and equipment employed in this study were well
tolerated by women and offer an opportunity for an objec-
tive documentation of the traction forces employed during
vacuum extractions.
A unique feature of this study is the ability to measure
the traction force during a vacuum extraction employing a
metal cup. It is commonly agreed17 that plastic cups are
1814
best suited for outlet and low-cavity vacuum extractions.
This seems to have resulted in a skewed distribution of the
different types of vacuum extractions with a bias towards
fewer outlet vacuum extractions employed in this study.
This bias also accounts for the higher rate of failed vacuum
extractions observed in the study (9%) compared with the
same rate for the whole hospital (5.2% obtained from qual-
ity control databases). The exclusion of early cases of vac-
uum extractions within the study period was due to initial
technical difficulties with the force sensor equipment and
also lack of awareness of the study among staff, but we do
not think that this has led to any systematic bias.
The clinical features associated with failed vacuum
extractions observed in this study are consistent with those
reported in the existing literature such as a higher inci-
dence of high birthweight.10
Interpretation (in light of other evidence)
There is no general consensus as to what would be a safe
level of traction force to employ during a vacuum extrac-
tion, or even whether the traction force should be consid-
ered as a relevant risk factor for perinatal morbidity at all.
The results of this study add no further clarity to this issue.
Malmstrom18 claimed that the fetal head is protected from
significant pressure impact because of an even distribution
of the forces on the presenting part and counteracting
forces within the skull. However, there is a risk of rupture
of the sagittal sinus and tearing of the falx at its attachment
to the tentorium if excessive traction force is employed
during the procedure. The head would risk becoming
exceedingly elongated and flattened, and there may be
damage to the brain and intracranial blood vessels in case
of unintentional cup detachment.19 A traction force of
225 N (corresponding to a mass equivalent of 23 kg) has
been suggested as an upper limit for safe forceps deliv-
ery.20–23 Moolgaoker et al.21 suggested a safe traction force
of up to 216 N using the 50 mm Malmstrom metal cup
with 80 kPa negative pressure. Up to a traction force of
200 N, the compression effect on the fetal head amounts to
only 10–40 N, but this increases rapidly if the employed
traction force exceeds 200 N.24 Hence, there are reasonable
models for understanding how excessive traction forces
could be harmful, but these mechanisms are still poorly
understood.
It might be argued that mid-cavity vacuum extractions
should be avoided because such deliveries are at a high risk
of failure or of requiring excessive traction forces. In the
present study, 38% of the vacuum extractions were per-
formed with the fetal vertex at the mid-cavity station. Of
these, 63% were classified as minimum or average vacuum
extractions, and 79% of them were successful. A substantial
number of late second-stage caesarean sections were proba-
bly avoided in this group. On the other hand, there were
ª 2015 Royal College of Obstetricians and Gynaecologists

16 failed mid-cavity vacuum extractions with an increased
risk of adverse perinatal outcome.
Previous studies on traction forces employed with rigid
plastic cups have reported that peak traction forces <113 N
would be sufficient in 80–86% of vacuum extractions.14,15
and therefore it has been suggested that most extractions
should not require more force than this. Limitations to
employing a force sensor with a rigid plastic cup include a
constructional limit for measuring the traction force to a
maximum of 137 N and the force data cannot be stored.
In the present study, only 8% of vacuum extractions show
peak traction forces below this upper limit and 33.5% of
the vacuum extractions study employed a maximum trac-
tion force exceeding the suggested safe maximum force
level of 216 N.21
It is feasible that the force measurement device used in
this study can be used to provide the obstetrician with
instantaneous feedback of applied traction force, so making
it easier to adhere to any quantitative maximum safe trac-
tion force recommendations.
Our results regarding pull force profiles, showing a
reduction in the traction force employed with each succes-
sive pull, are in contrast to that reported by Vacca,15 who
observed an increase in the traction force in the final peri-
neal phase compared with the pulls during the descending
phase. One possible explanation for this observation is the
higher proportion of low-cavity and outlet vacuum extrac-
tions recruited in the study by Vacca15 compared with the
present study.
Conclusions
The unexpectedly high traction forces employed during
vacuum extractions in this study can be associated with
generally good neonatal outcome. However, our data do
not provide any evidence on the maximum safe level of
traction force that can be employed during vacuum extrac-
tion.
As obstetricians tend to underestimate the force applied
during vacuum extraction, objective measurement with
instantaneous feedback may be valuable in raising aware-
ness.
Disclosure of interest
GA, MW, DS and KY are owners of MED3TEC, which is
developing the technical device described in this work.
Contribution to authorship
MW and GA had the idea and carried out the design of
the original study. KY, DS, JA, KP and GA were responsi-
ble for data collection. GA, KP and JA carried out the
analyses. GA and KP drafted the article, which was revised
by all authors.
ª 2015 Royal College of Obstetricians and Gynaecologists
Traction force during vacuum extraction
Details of ethics approval
Ethical approval was given by the local ethics committee of
Stockholm, Sweden (D:nr 2012/1553-31/1).
Funding
Funding was received from the Swedish Patient Insurance
(LÖF) and a grant from the Karolinska Institute, Depart-
ment of Obstetrics and Gynaecology.
Acknowledgements
We are very grateful to the women who participated in the
study, the staff at the delivery ward at Karolinska Univer-
sity Hospital, Huddinge, and Henry Nisell for assistance
with calculations and peer reviewing. &
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ª 2015 Royal College of Obstetricians and Gynaecologists