OBJECTIVE To investigate the pain relief used in association with vacuum extraction assisted deliveries and to identify risk factors for not receiving pain relief during the procedure. METHODS Retrospective birth register study. METHODS Nationwide study in Sweden. METHODS The study population consisted of all women (n = 62 568) with a singleton pregnancy who gave birth in gestational weeks 37(+0) to 41(+6) between 1999 and 2008 and were delivered by vacuum extraction. METHODS Register study with data from the Swedish Medical Birth Register. METHODS Epidural blockade, spinal blockade, pudendal nerve blockade, infiltration of the perineum, no pain relief. RESULTS In all, 32.4% primiparas and 51.4% multiparas who had a vacuum-assisted delivery had this without potent pain relief such as epidural blockade, spinal blockade or pudendal nerve block. When infiltration was added as a method for pain relief, 18% were still delivered without pain relief. Multiparas were more likely than primiparas to be delivered without potent pain relief, odds ratio (OR) 2.29 95% confidence interval (CI) (2.20-2.38). Compared with women delivered by vacuum extraction due to prolonged labor, those with signs of fetal distress were more likely to be delivered without potent pain relief (OR) 1.74, 95% (CI) (1.68-1.81). CONCLUSIONS A considerable number of women are delivered by vacuum extraction without pain relief. The high proportion might reflect that clinical staff do not always consider pain relief to be of high priority in vacuum extraction deliveries or that they fear impaired pushing forces.