Vacuum-assisted birth and its acceptance by clinicians will be determined to a large extent by the number of successful births achieved and by the outcomes for the mother and infant. Clinical audits and system analyses often identify deficient knowledge and inadequate operator training as important contributors to adverse outcomes. The design of a vacuum cup is the major factor that determines its manoeuvrability within the lower birth canal and therefore its appropriate clinical use. Vacuum cups that are commercially available include: soft anterior cups, rigid anterior cups, and rigid posterior cups. This chapter describes the five steps of a vacuum-assisted birth: locating the flexion point and calculating the cup-insertion distance, holding and inserting the cup, manoeuvring the cup toward the flexion point, inducing and maintaining the vacuum, and traction method. Recent evidence has demonstrated that midline episiotomy is significantly associated with higher rates of perineal trauma compared with mediolateral episiotomy.