Forceps, vacuum, and breech extraction for difficult delivery of an unengaged fetal head during cesarean birth: a retrospective cohort study

OBJECTIVES: To compare perinatal outcomes, primarily neonatal transcutaneous bilirubin levels and the need for phototherapy, associated with three fetal extraction techniques used during cesarean birth after difficult or failed manual delivery of an unengaged fetal head: short forceps, vacuum, and breech extraction. METHODS: A retrospective, single-center analytical study was conducted including all cesarean births performed between July 2022 and July 2025 in which fetal extraction was considered difficult and required the use of short forceps, vacuum, or breech extraction. Only singleton, term, cephalic pregnancies without labor onset were included. Maternal, surgical, and neonatal data were collected and analyzed. Multivariable analyses were adjusted for surgeon experience. RESULTS: A total of 98 cesarean births met the inclusion criteria. Short forceps were used in 60 (61.2 %), vacuum extraction in 25 (25.5 %), and breech extraction in 13 (13.3 %) births. Transcutaneous bilirubin levels at 48 h of life did not differ significantly between extraction techniques. Phototherapy was required in 8.3 % of neonates following forceps, in 20.0 % following vacuum, and in none following breech extraction; these differences were not statistically significant. After adjustment for surgeon experience, the use of forceps or vacuum was not independently associated with transcutaneous bilirubin levels or phototherapy requirement. In contrast, procedures performed by highly experienced obstetricians were associated with a significantly lower likelihood of phototherapy requirement. CONCLUSIONS: In cesarean births complicated by difficult fetal extraction of an unengaged fetal head, neonatal bilirubin levels and phototherapy requirement were not associated with extraction technique but were associated with surgeon experience.