AbstractBackgroundProlonged second stage of labour is an important cause of maternal and perinatal morbidity and mortality. Vacuum extraction (VE) and second‐stage caesarean section (SSCS) are the most commonly performed obstetric interventions, but the procedure chosen varies widely globally.ObjectivesTo compare maternal and perinatal morbidity, mortality and other adverse outcomes after VE versus SSCS.Search StrategyA systematic search was conducted in PubMed, Cochrane and EMBASE. Studies were critically appraised using the Newcastle–Ottawa scale.Selection CriteriaAll artictles including women in second stage of labour, giving birth by vacuum extraction or cesarean section and registering at least one perinatal or maternal outcome were selected.Data Collection and AnalysisThe chi‐square test, Fisher exact's test and binary logistic regression were used and various adverse outcome scores were calculated to evaluate maternal and perinatal outcomes.Main ResultsFifteen articles were included, providing the outcomes for a total of 20 051 births by SSCS and 32 823 births by VE. All five maternal deaths resulted from complications of anaesthesia during SSCS. In total, 133 perinatal deaths occurred in all studies combined: 92/20 051 (0.45%) in the SSCS group and 41/32 823 (0.12%) in the VE group. In studies with more than one perinatal death, both conducted in low‐resource settings, more perinatal deaths occurred during the decision‐to‐birth interval in the SSCS group than in the VE group (5.5% vs 1.4%, OR 4.00, 95% CI 1.17–13.70; 11% vs 8.4%, OR 1.39, 95% CI 0.85–2.26). All other adverse maternal and perinatal outcomes showed no statistically significant differences.ConclusionsVacuum extraction should be the recommended mode of birth, both in high‐income countries and in low‐ and middle‐income countries, to prevent unnecessary SSCS and to reduce perinatal and maternal deaths when safe anaesthesia and surgery is not immediately available.