Caesarean sections in the second stage of labour – a risk evaluation

Abstract

Objective: To retrospectively analyse the relative rate of complications of caesarean sections performed in the second stage, in comparison to those done in the first stage of labour, in singleton uncomplicated pregnancies. A secondary objective was to see whether a conscious attempt had been made for an instrumental delivery where it seemed feasible to avert a caesarean in the second stage of labour. Method: A retrospective cohort study of 2440 caesarean sections out of a total of 5349 procedures done in 2019 and 2020, at ward 10, at a shocking rate reaching 49% and 60% (university, health ministry units) at the Teaching Hospital, Peradeniya. The instrumental delivery rate was a mere 1.63% in 2020. There were only 1220 caesareans performed in the second stage of labour. Hence, only a similar number (1220) of cases were selected from first stage procedures for the purpose of comparison of complications. Results: Requirement of blood transfusions; intraoperative or within 24 hours of delivery were 6 against 36 instances for first and second stage respectively. There were 16 recorded instances of extensions of angles or tears, and 3 cases of broad ligament haematomas in the second stage procedures. There was one instance of even a vaginal tear dislodging a jammed fetal head following failed forceps. Only 3 records of angle extensions were recorded when attempting to deliver high floating heads during the first stage. Uterine scar dehiscence was found in 36 instances in second stage procedures against 12 in the first but this was not a result of the procedure but the longer duration of labour in the former situation. There were two recorded instances of bladder injury in the first stage against 7 in the second. The mean duration of hospital stay was markedly different at 2.2 and 4.6 days. 6 against 17 patients ended in the high dependency unit or the ICU due to procedure-related complications. There were no mortalities. The mean operating times from the sample drawn from operating theatre records (300 of each stage) drawn was 28.6 min against 46.5 min. Failed forceps and ventouse were recorded in only 2 instances. Conclusions: Second stage caesareans seemed more technically difficult as judged by the longer time taken and were more likely to be complicated and result in a longer hospital stay and a higher risk of admission to Intensive care. We cannot conclude that they were any safer than AVD, as a comparison with complications of AVD were not audited in this study. Better training in instrumental delivery may improve an unacceptable situation where half the women (49%) had caesarean deliveries in 2019. Failed trial of instrumental delivery and any resultant injury should not result in automatic reprimand of the operator as this leads to performing caesareans as defensive medicine. Senior-most obstetricians on site must be called in for second stage caesareans with higher morbidity. This is more so when a trial of AVD has failed.