Caesarean section at full

dilatation: incidence, impact and

current management
INTRODUCTION

 The incidence of caesarean sections performed at full dilatation is

increasing, and may now represent around 8000 deliveries in the
UK
each year.
 A CS at full dilatation occurs when a mother requires delivery in
the second stage of labor, which may pose as a risk to herself or
the fetus, and cannot be dealt with by assisted vaginal delivery.
This includes
1. prolonged second stage of labor
2. fetal compromise.
The changing incidence of
caesarean sections at full
dilatation
 In association with the increasing incidence of CS at full
dilatation, increasing rates of failed operative vaginal delivery
and reduced attempts at instrumental delivery have also been
documented. The reasons for this are likely to be multifactorial.

 It is recognized that adequate clinical experience and appropriate

training are essential for safe performance in complicated
deliveries.
 Current guidelines recommend that operative vaginal deliveries
should only be conducted when competency has been achieved
or when the consultant is present. It is also recommended that
senior obstetricians should be involved with decision-making and
delivery in these difficult cases.

 The increased risk of neonatal trauma and admission to specialist

care following excessive pulls (>3) during instrumental delivery is
well documented. This, in combination with a rise in increasing
obstetric malpractice litigation, may contribute to the higher
numbers of caesareans in the second stage of labour, as it is
perceived the safer option.
Impact of caesarean sections at
full dilatation
Maternal morbidity

 Caesarean section at full dilatation is associated with more than

double the risk of intraoperative trauma compared with CS during
the first stage of labour . Maternal intraoperative trauma is
reported to occur in the range of 10% to 27% of CS at full
dilatation
1.laceration to bladder
2.bowel injury
3.extension of uterine incision
 Maternal hemorrhage (>1000 ml) is reported to occur in between
4.7% and 10% of CS at full dilatation. CS at full dilatation is
associated with increased rates of hemorrhage compared with CS
during the first stage of labor.
 The psychological impact of either vaginal or abdominal
operative delivery in the second stage is likely to be significant
and long lasting.
 Women undergoing operative vaginal delivery are more likely to
experience urinary incontinence and constipation than following
CS at full dilatation.
Neonatal morbidity

 Overall rates of severe neonatal trauma following both CS at full

dilatation and CS during the first stage of labor are very low.

 Delivery by CS at full dilatation has been shown to result in more

admissions due to reduced Apgar score and umbilical artery pH
compared with babies born by successful operative vaginal
delivery .
 Babies born by CS at full dilatation are 1.5 times more likely to
have perinatal asphyxia than those born by CS during the first
stage of labour.

 However, this is likely to be a result of increasing fetal

compromise with prolonged duration of delivery, not a result of
the procedure.
Should operative vaginal
deliveries be attempted?

 The data suggest that maternal and neonatal risks do not seem
to escalate following an attempt at operative vaginal delivery.
However, the decision to attempt operative vaginal delivery
should be made on an individual patient basis with support from
senior obstetricians.
 Consideration of gestation,
 duration of labour prior to intervention,
 cardiotocography
 scalp sampling should all guide management decisions.
Techniques for delivery of
caesarean section at full dilatation
Exposure
 In the UK the most common incision for CS is transverse
abdominal incision. NICE advises that the Joel-Cohen incision – a
straight incision 3 cm above the pubic symphysis then blunt
opening of subsequent layers – should be performed.
ADVANTAGES
1. reduce levels of postoperative febrile morbidity
2. shorter operating times.
 When performing CS at full dilatation, a higher incision in the
uterus may be necessary. This is because the lower uterine
segment is stretched, obscuring the anatomical landmarks that
differentiate between vagina, cervix and uterine body.
 A standard incision may risk incising the bladder or the vagina, or
may affect the integrity of the cervix.
 Lower-segment incisions may also be at increased risk of tearing
and be more difficult to repair.
Disimpacting the head

 The problem of disimpacting the fetus from the pelvis can be

confounded by ongoing uterine contractions. Syntocinon
infusions should be stopped as soon as the decision to proceed
with CS is made.
 It is thought good practice to perform a vaginal examination in
the operating theatre prior to surgery. Confirmation of fetal
position and station can inform the method of delivery.
Push Method

 The woman being placed in semi-lithotomy position and fetal

head being pushed up from the vagina by an assistant while the
operating surgeon applies upward traction on the baby.
 It is important that an experienced technician be employed to
spread equal pressure over the fetal head. Pressure at a single
point is more likely to cause fetal trauma. If possible, the head
should be flexed to narrow the diameter and ease delivery.
Complications

 increased trauma to the lower uterine segment due to

manipulation of the fetal head.
 a theoretical increased risk of infection due to contamination
from vaginal flora
 risk of fetal scalp trauma.
 endometritis
Pull Method

 The reverse breech extraction or ‘pull’ method involves grasping

one or both fetal feet at the fundus of the uterus and applying
steady traction in the downward direction. Buttocks then follow
and flexion of the spine occurs at the thoracolumbar region. This
allows more space to deliver the fetal head.
Complications

 risk of extension to the uterine incision

 neonatal trauma from traction of limbs.
Medical devices
 The Fetal Dis -impacting System consists of a silicone balloon
that can be inserted through the vagina to rest under the fetal
head. It can then be inflated with saline in an attempt to elevate
the fetal head
 The C-snorkel is an anatomically curved tube with multiple
ventilation ports. It can be inserted between the vaginal wall and
fetal head, and aeration through the ports can alleviate the
vacuum between them, aiming to lessen the force required to
dis-impact the fetal head.
Conclusion

 Caesarean sections during the second stage are increasing in

prevalence and are associated with significant long-term
psychological and physical maternal morbidity.
 it is important that obstetric trainees have adequate supervised
training opportunities in order to improve recognition of necessity
for CS at full dilatation, as well as competence and confidence for
performing vaginal instrumental deliveries.
THANK YOU