Introduction
This study aimed to assess risk factors for difficult fetal extraction in emergency caesarean sections, focusing on top-up epidural anesthesia compared to spinal anesthesia. Additionally, this study addressed consequences of difficult fetal extraction on neonatal and maternal morbidity.

Material and Methods
This retrospective registry-based cohort study included 2,332 of 2,892 emergency caesarean sections performed with local anesthesia during 2010–2017. Main outcomes were analyzed by crude and multiple adjusted logistic regression providing odds ratios.

Results
Difficult fetal extraction was found in 14.9% of emergency caesarean sections.

Risk-factors for difficult fetal extraction included top-up epidural anesthesia (aOR:1.37[95 %CI 1.04–1.81]), high pre-pregnancy BMI (aOR:1.41[95 %CI 1.05–1.89]), deep fetal descent (ischial spine: aOR:2.53[95 %CI 1.89–3.39], pelvic floor: aOR:3.11[95 %CI 1.32–7.33]), and anterior placental position (aOR:1.37[95 %CI 1.06–1.77]). Difficult fetal extraction was associated with increased risk of low umbilical artery pH 7.00–7.09 (aOR:3.50[95 %CI 1.98–6.15]) pH ≤ 6.99 (aOR:4.20[95 %CI 1.61–10.91]), five-minute Apgar score ≤ 6 (aOR:3.41[95 %CI 1.49–7.83]) and maternal blood loss (501–1,000 ml: aOR:1.65[95 %CI 1.27–2.16], 1,001–1,500 ml: aOR:3.24[95 %CI 2.24–4.67], 1,501–2,000 ml: aOR:3.94[95 %CI 2.24–6.94] and ≥ 2001 ml: aOR:2.76[95 %CI 1.12–6.82]).

Conclusion
This study identified four risk factors for difficult fetal extraction in emergency caesarean section: top-up epidural anesthesia, high maternal BMI, deep fetal descent and anterior placental position. Additionally, difficult fetal extraction was associated with poor neonatal and maternal outcomes.