The clinical and radiologic descriptions of three neonates with tentorial hemorrhage after vacuum extraction are reported. All patients were full term, with Apgar scores of 8 or more; one patient experienced fetal distress during delivery. Within 36 hours after birth, the neonates had multiple generalized seizures; computed tomography or magnetic resonance imaging outlined distinctive tentorial hemorrhages with extension over the superior surface of the cerebellum or inferior surface of the occipital lobe. One patient had diffuse hypoxic-ischemic injury, and another had bilateral temporal lobe infarcts. Treatment included medical control of seizures and intracranial hypertension; one patient had surgical evacuation of bilateral subdural hematomas. Follow-up from 1 to 5 years showed significant developmental delays in two patients. These cases demonstrate that the forces generated on the fetal cranium by vacuum extraction are similar to those produced by forceps and result in tentorial laceration, venous rupture, and subdural hemorrhage. Because these hemorrhages may be associated with significant ischemic injury, serial radiologic evaluation is recommended for the detection of persistent structural abnormalities.