Management of Complicated Second Stage Caesarean Section
Understanding the Clinical Challenge
Second stage caesarean sections carry significantly higher maternal and fetal morbidity compared to first stage procedures, requiring specific technical approaches and anticipatory management to minimize complications. 1, 2, 3
The second stage caesarean (performed at full cervical dilation with the fetal head deeply impacted in the pelvis) presents unique technical difficulties including increased risk of uterine incision extension (12.5%), postpartum hemorrhage, and neonatal complications requiring intensive care admission (15.3%) 1, 2.
Pre-operative Preparation and Team Planning
Multidisciplinary Team Assembly
- Ensure a second experienced obstetrician is present before proceeding, particularly for anticipated difficult extractions 4
- Confirm availability of experienced anesthesiologist familiar with obstetric complications 4
- Alert neonatal resuscitation team for immediate availability, as NICU admission rates are significantly elevated (15.3-34.2%) 1, 2
- Verify blood products are immediately available given increased transfusion risk 3
Anesthetic Considerations
- Regional anesthesia (spinal or epidural) is strongly preferred over general anesthesia to avoid airway complications and allow maternal participation 4
- If epidural already in place from labor, extend the block rather than converting to general anesthesia 4
- Have difficult airway equipment immediately available if general anesthesia becomes necessary 4
Intra-operative Technical Management
Delivery Technique for Deeply Impacted Head
The modified Patwardhan technique (reverse breech extraction) is superior to head pushing for deeply impacted fetal heads, reducing uterine incision extension, blood loss, and operative time. 5
Reverse Breech Extraction Technique:
- When the head is deeply embedded in the pelvis (especially in occipito-posterior position):
Evidence supporting this approach: Four randomized trials (357 women) demonstrated reverse breech extraction significantly reduces uterine incision extension (RR 0.23,95% CI 0.13-0.40) and mean blood loss (MD -294.92 mL) compared to head pushing 5.
Alternative Extraction Methods
- Tocolytic agents (nitroglycerin) may facilitate delivery but evidence is insufficient for routine recommendation 5
- Vacuum or forceps assistance has insufficient evidence for routine use at caesarean section 5
- Avoid prolonged attempts at manual extraction which increase tissue trauma and bleeding 5
Management of Specific Complications
Uterine Incision Extension
- Most common intra-operative complication (12.5% incidence) 1
- Immediately identify the extent of extension - lateral extensions risk uterine vessels 1, 3
- Secure hemostasis with figure-of-eight sutures at bleeding points 6
- Consider uterine artery ligation if bleeding persists 6
Postpartum Hemorrhage
- Occurs in 18.8% of second stage caesareans 1
- Administer oxytocin immediately after delivery (single IV dose) 4
- Avoid ergometrine - contraindicated due to risk of bronchospasm and cardiovascular instability 4
- Have additional uterotonics ready (carboprost, misoprostol) 4
- Administer single IV dose of furosemide after delivery to manage auto-transfusion from contracted uterus 4
Bladder or Bowel Injury
- Higher risk with previous caesarean sections and prolonged second stage 3
- Identify injuries intra-operatively through systematic inspection 6
- Involve urologist/general surgeon immediately for repair 6
Postoperative Management
Maternal Monitoring
- Continuous monitoring for first 24 hours given increased risk of delayed hemorrhage 1, 3
- Monitor for signs of endometritis (18.8% incidence) - fever, uterine tenderness, foul lochia 1, 2
- Wound infection occurs in 4.8% - inspect daily 1
- Expect hospital stay of 7-14 days (longer than routine caesarean) 1
Neonatal Considerations
- Anticipate NICU admission requirement (15.3% of cases) 1
- Monitor for hyperbilirubinemia (9.7% incidence) 1
- Assess for birth trauma, though rare with proper technique 5
- Meconium-stained amniotic fluid present in 34.2% of cases 1
Critical Decision Points During Labor
When to Proceed vs. Attempt Instrumental Delivery
- 92.4% of second stage caesareans are performed without trial of instrumental delivery 2
- Consider attempted operative vaginal delivery (forceps/vacuum) if:
Indications for Second Stage Caesarean
- Non-reassuring fetal status (most common indication) 1
- Cephalopelvic disproportion (92.4% of cases) 2
- Failed instrumental delivery 4
- Maternal exhaustion with lack of progress 2
Common Pitfalls to Avoid
- Never underestimate the difficulty - second stage caesareans have 2-3 fold higher complication rates than first stage 3
- Do not proceed without experienced assistance - call for senior help early 4
- Avoid excessive fundal pressure during manual extraction - increases uterine trauma 5
- Do not use ergometrine for third stage management - use oxytocin only 4
- Never delay blood product availability - transfusion rates are significantly elevated 3
- Avoid general anesthesia unless absolutely necessary - regional techniques are safer 4
Surgical Technique Modifications
Incision Considerations
- Use Joel-Cohen incision for improved outcomes 4
- Consider vertical uterine incision if transverse access is severely limited 6
- Do not close peritoneum - associated with better outcomes 4