Fetal extraction maneuvers during cesarean delivery in the second stage of labor

Objective: To compare maternal and neonatal outcomes following cesarean delivery during second stage of labor, according to the fetal extraction method. Methods: A retrospective cohort study of all women who underwent term cesarean delivery during the second stage of labor at a university-affiliated tertiary medical center (2012–2016). The cohort was divided according to three extraction methods: standard vertex extraction, the push method in which the head extraction is accompanied by pushing through the vagina, and the reverse breech extraction method. Primary outcomes were intraoperative maternal complications, and secondary outcomes were neonatal adverse events. Results: Three hundred and fifty women were included, of whom 206 (59%) underwent standard vertex fetal extraction, 116 (33%) the push method extraction, and 28 (8%) reverse breech extraction. Operation time was significantly shorter in the standard vertex extraction method compared to push and reverse breech extraction methods (33.5 vs. 40.5 and 39.0 min, respectively, p =.013). Uterine laceration and incision extension frequencies were lower in the vertex extraction method as well (24.76 vs. 45.69–46.40% in others, p <.001). Delivery related neonatal injury was significantly more frequent in the reverse breech extraction method (39.29 vs. 12–15% in others, p <.001). In a multivariate analysis reverse breech extraction was associated with higher rates of uterine laceration and incision extension (OR = 2.739 95% confidence interval 1.44–6.56, p =.0237) and delivery related neonatal injury (OR = 2.837, 95% CI: 1.081–7.448, p =.0342). Conclusion: Standard vertex extraction method during second stage of labor cesarean delivery is safer both to the mother and neonate when compared to alternative extraction methods. Abbreviations: NRFHR: non-reassuring fetal heart rate; NICU: neonatal intensive care unit.