DOI: 10.1111/tog.

12112 2014;16:199–205
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Caesarean section at full dilatation: incidence, impact and

current management
Nicola Vousden MBBS BSc,a,* Zillah Cargill BSc,
b
Annette Briley MSc,
c
Graham Tydeman MRCOG,
d

Andrew H Shennan MD FRCOGe

a
Academic Clinical Fellow in Obstetrics and Gynaecology, Division of Women’s Health, Women’s Health Academic Centre, and Maternal and Fetal
Research Unit, King’s College London, Division of Reproduction and Endocrinology, St Thomas’ Hospital, London SE1 7EH, UK
b
Final year medical student, Division of Women’s Health, Women’s Health Academic Centre, King’s College London, St Thomas’ Hospital, London
SE1 7EH, UK
c
Consultant Midwife, Division of Women’s Health, Women’s Health Academic Centre, King’s College London, St Thomas’ Hospital, London SE1
7EH, UK
d
Consultant in Obstetrics and Gynaecology. Department of Obstetrics and Gynaecology, NHS Fife, KY2 5AH, UK
e
Professor of Obstetrics, Division of Women’s Health, Women’s Health Academic Centre, King’s College London, St Thomas’ Hospital, London
SE1 7EH, UK
*Correspondence: Nicola Vousden. Email: nicola.vousden@kcl.ac.uk

Accepted on 26 March 2014

Key content Learning objectives

 The incidence of caesarean sections performed at full dilatation is  Assess the reasons for the increasing incidence of full dilatation
increasing, and may now represent around 8000 deliveries in the caesarean section at full dilatation.
UK each year.  Describe the associated maternal and neonatal risks compared with
 Delivery can be technically challenging due to fetal impaction operative vaginal delivery.
into the pelvis, and may be associated with greater maternal  Describe the current evidence for optimal management and define
and fetal morbidity even without failed attempt at areas for research.
vaginal delivery.
Ethical issues
 Guidelines are needed to define optimal management,
 Further research is needed to define long-term morbidity and
including the use of new devices to teach or assist
address the risk/benefit of second-stage caesarean section at full
safe delivery.
dilatation versus attempted vaginal delivery.
 Best practice should be incorporated into structured training
programmes such as Managing Obstetric Emergencies and Keywords: caesarean section / fetal morbidity / full dilatation /
Trauma (MOET). simulation / maternal morbidity

Please cite this paper as: Vousden N, Cargill Z, Briley A, Tydeman G, Shennan AH. Caesarean section at full dilatation: incidence, impact and current
management. The Obstetrician & Gynaecologist 2014;16:199–205.

individual practice and senior support make it difficult to

estimate the impact nationally but this could represent ~8000
deliveries each year. International rates are likely to be
Introduction
influenced by skills and training but have been documented
In 2010 more than 160 000 babies were born by caesarean to be similar (4.4% in Singapore in 20094).
section (CS) in the UK. Approximately 60% of these were A CS at full dilatation occurs when a mother requires
classed as emergency CS, a proportion that has delivery in the second stage of labour, which may pose as a
remained similar throughout the previous decade.1 risk to herself or the fetus, and cannot be dealt with by
However, the incidence of CS performed at full dilatation assisted vaginal delivery. This includes prolonged second
has increased (0.9% of women reaching full dilatation in stage of labour and fetal compromise. The fetal head can be
1993 versus 2.2% in 2001, P < 0.05;2 0.9% in 2006 versus deeply impacted into the pelvis, making the procedure
1.8% in 2008, P = 0.0033). The largest to study to date, an technically difficult and associated with greater maternal and
audit of all deliveries at a tertiary hospital in London over a fetal morbidity.5
10-year period, demonstrated that 5% (n = 458) of CSs were This literature review aims to assess the reasons for the
performed at full dilatation.2 Variability in case mix, increasing incidence of CS at full dilatation. It also aims to

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 Caesarean section at full dilatation: the current evidence

describe the associated complications and current evidence litigation claims were related to operative vaginal deliveries
for safe management of this frequently occurring, compared with 44% for CS.14
high-risk situation. Maternal factors are also likely to contribute to the
increased incidence of CS in general. One study of maternal
characteristics over a 12-year period observed trends of
The changing incidence of caesarean
increasing maternal age and increasing nulliparous
sections at full dilatation
deliveries.15 These are all established risks for CS15 but no
In association with the increasing incidence of CS at full evidence has examined the correlation with CS at full
dilatation, increasing rates of failed operative vaginal delivery dilatation. Increasing maternal body mass index prior to
(8.4% in 1992 versus 12.9% in 2001, CC 0.93, P < 0.05) pregnancy has also been documented.15 Whereas this is
and reduced attempts at instrumental delivery (3.9% no associated with overall increased risk of CS, rates of CS at full
attempt at instrumental in 1992 versus 5.3% in 2001, CC dilatation are not affected.16,17
0.47, P = 0.002) have also been documented.2 The reasons for
this are likely to be multifactorial.
Impact of caesarean sections at full
Under the European Working Time Directive (EWTD),
dilatation
junior doctors work significantly fewer hours.6 Although this
is a recent development (introduced in 1998) it may further Both elective and emergency CS have a higher risk of
compound the issue. The General Medical Council report on complications than a vaginal birth. A CS in second stage of
the impact of EWTD has recognised issues with junior trainees labour has additional associated risks for both the mother
obtaining the required surgical competencies and that the and fetus due to the nature of this emergency situation. There
number of trainees requiring extensions of their clinical is considerable heterogeneity in studies assessing maternal
training was increasing (6–40% in 2008 versus 25–55% in and neonatal complications.
2009).7 It is recognised that adequate clinical experience and
appropriate training are essential for safe performance in Maternal morbidity
complicated deliveries.8 Reduced training time and working Caesarean section at full dilatation (n = 549) is associated
hours may result in less exposure to, and thus less confidence with more than double the risk of intraoperative trauma
in, performing instrumental vaginal deliveries. compared with CS during the first stage of labour (n = 1074)
Current guidelines recommend that operative vaginal [adjusted relative risk (RR) 2.6, 95% CI 1.71–3.88, P < 0.001,
deliveries should only be conducted when competency has n = 1623].5 Maternal intraoperative trauma, such as
been achieved (as assessed by RCOG Objective Structured laceration to bladder or bowel or extension of uterine
Assessment of Technical Skills9) or when the consultant is incision, is reported to occur in the range of 10%5 to 27%18
present.10 It is also recommended that senior obstetricians of CS at full dilatation (n = 549 and n = 199, respectively).
should be involved with decision-making and delivery in It is difficult to compare rates and severity of maternal
these difficult cases.8 Consultant input in decision-making trauma following CS to that following operative delivery due
has been shown to reduce rates of emergency CS by 40%.11 to the inherent differences in technique. One prospective
However, deliveries are more common out of working cohort study of 393 operative deliveries found that 24%
hours.2,12 Despite recent improvements,3 nearly half of (n = 50) of women having had CS at full dilatation had
deliveries at night do not have senior supervision (54% extension of the uterine incision and 8% (n = 15) of women
supervised compared with 71% during the day12). Although having had operative delivery developed third-degree tears.19
consultant cover is increasing, it is far from 100% in most The potential morbidity of events following difficult vaginal
units. This serves to highlight the requirement for adequate or abdominal deliveries cannot be easily compared; both
training and appropriate sign-off of those covering at night. are undesirable.
The increased risk of neonatal trauma and admission to Maternal haemorrhage (>1000 ml) is reported to occur in
specialist care following excessive pulls (>3) during between 4.7%5 and 10%19 of CS at full dilatation. CS at full
instrumental delivery is well documented.13 This, in dilatation is associated with increased rates of haemorrhage
combination with a rise in increasing obstetric malpractice compared with CS during the first stage of labour (4.7% versus
litigation, may contribute to the higher numbers of 2.9%, adjusted RR 1.7, 95% CI 1.0–3.0).5 Rates of maternal
caesareans in the second stage of labour, as it is perceived haemorrhage have been found to be considerably higher
the safer option. In 2010, £729 million was paid out for following CS at full dilatation than successful operative vaginal
clinical negligence in the National Health Service. Over the delivery (10% versus 3%, adjusted OR 2.82, 95% CI 1.10–
last decade, maternity claims have accounted for both the 7.62).19 Low rates of maternal sepsis, wound infection and
second highest number of claims and the highest value of postoperative pyrexia are reported in the majority of studies
claims.14 However, ~11% of the total values of maternity regardless of route of delivery.5,19

200 ª 2014 Royal College of Obstetricians and Gynaecologists

 Vousden et al.

Few studies have assessed the long-term maternal rates of neonatal intracranial haemorrhage are greater
morbidity associated with operative delivery. One cohort following operative vaginal delivery than CS.25,26 This does
study of 393 women who had undergone either operative suggest that the delivery itself can be traumatic.
vaginal delivery in theatre or CS at full dilatation found that Delivery by CS at full dilatation has been shown to result in
73% of those who were considering further pregnancy had more admissions to SCBU due to reduced Apgar score and
achieved a further pregnancy after 3 years.20 Nearly one-third umbilical artery pH compared with babies born by successful
of the cohort wished to avoid further pregnancy. The most operative vaginal delivery (11% of 209 deliveries versus 6% of
commonly stated reason was that they ‘could not go through 184 deliveries respectively; adjusted OR 2.64, 95% CI 1.16–
childbirth again’, with no significant difference between 6.02).19 Babies born by CS at full dilatation are 1.5 times more
women with prior operative vaginal delivery or CS (51% likely to have perinatal asphyxia than those born by CS during
versus 42% respectively).20 Women were more likely to aim the first stage of labour (11% of 549 deliveries versus 8% of
for (87% versus 33%, adjusted OR 15.55, 95% CI 5.25– 1074 deliveries; 95% CI 1.06–2.14, P < 0.05).5 However, this is
46.04), and to have, a successful vaginal delivery following likely to be a result of increasing fetal compromise with
previous operative delivery than following CS (78% versus prolonged duration of delivery, not a result of the procedure.
31%, adjusted OR 9.50, 95% CI 3.48–25.97).20 But operative Only one study has reported long-term follow-up; therefore,
vaginal delivery was associated with increased rates of the longer impact of these risks is not well documented. In this
moderate-to-severe pain during intercourse sufficient to study, children who were born in poor condition (e.g. Apgar
defer intercourse at 6 weeks after delivery (adjusted OR score <7 at 5 minutes; significant trauma or sepsis)
3.35, 95% CI 1.36–8.25).21 The psychological impact of either demonstrated low rates of neurodevelopment morbidity at
vaginal or abdominal operative delivery in the second stage is the age of 5 years, irrespective of whether they were delivered by
likely to be significant and long lasting. successful instrumental delivery or CS at full dilatation.27
Long-term morbidity, however, may differ according to
route of delivery. Women who have undergone operative Should operative vaginal deliveries be attempted?
vaginal delivery are less likely to report difficulty in A recent Cochrane review28 found no randomised controlled
conceiving (adjusted OR 0.33, 95% CI 0.12–0.98) and more trials comparing trial of instrumental vaginal delivery to
likely to have had a further pregnancy than following CS immediate CS for women with failure to progress in the
(adjusted OR 2.09, 95% CI 1.10–4.28).20 This supports other second stage. However, several cohort studies demonstrate
evidence demonstrating relative subfertility following all that an attempt at operative vaginal delivery prior to CS does
operative deliveries but increasingly following CS.22–24 not result in increased rates of immediate maternal morbidity
Women undergoing operative vaginal delivery are more compared to CS without attempt at operative vaginal delivery
likely to experience urinary incontinence at 6 weeks (adjusted (maternal haemorrhage,2,5,19 wound infection, or
OR 7.80, 95% CI 2.58–23.55) and at 1 year (adjusted OR intraoperative trauma5,19). Equally, there is no significant
3.12, 95% CI 1.27–7.64) than following CS at full dilatation.21 difference in rates of urinary or bowel complications a year
The frequency of constipation at one year was also higher after delivery following an attempt at operative vaginal
following operative delivery (adjusted OR 2.55, 95% CI 1.02– delivery prior to CS compared to immediate CS.21 No
6.37) but pain on opening bowels, haemorrhoids and loss of increase in neonatal trauma or sepsis has been
control of bowels was not significantly different between demonstrated,5,19 but attempted operative delivery prior to
groups.21 Therefore both operative vaginal delivery and CS at CS produces significantly lower arterial cord pH compared to
full dilatation can be associated with significant long-term immediate CS (mean pH 7.21 versus 7.25; P = 0.05).2
risk to the mother. These data suggest that maternal and neonatal risks do not
seem to escalate following an attempt at operative vaginal
Neonatal morbidity delivery. However, the decision to attempt operative vaginal
Overall rates of severe neonatal trauma following both CS at delivery should be made on an individual patient basis with
full dilatation and CS during the first stage of labour are very support from senior obstetricians. Consideration of gestation,
low (0.2% of 549 deliveries versus 0% of 1074 deliveries, duration of labour prior to intervention, cardiotocography and
respectively),5 but are reported for the former group. Studies scalp sampling should all guide management decisions.
that included all forms of trauma, such as scalp and facial
bruising, report that rates of neonatal trauma are higher
Reducing need for caesarean section at full
following operative vaginal delivery compared with CS (22%
dilatation
of 184 deliveries versus 9% of 209 deliveries, respectively; OR
0.37, 95% CI 0.20–0.70).19 More significant trauma such as Avoiding the need for CS at full dilatation includes
fractured clavicle and brachial plexus injury were also more appropriate management of labour, including judicious
common following operative vaginal delivery.19 Similarly stimulation with oxytocin and correction of fetal

ª 2014 Royal College of Obstetricians and Gynaecologists 201

 Caesarean section at full dilatation: the current evidence

malposition. A detailed description of this procedure is also anecdotally reported that pressure from below prior to
outside the remit of this article but individual hospital trust initiating surgery can disimpact the fetal head, easing delivery,
policy and national guidelines should be taken but there is no evidence to support this.
into consideration. Intraoperative disengagement of the fetal head continues
to pose a challenge to obstetricians and the method chosen
may depend on the skill and experience of the surgeon.
Techniques for delivery of caesarean
Several techniques have been reported in the literature. The
section at full dilatation
‘push’ method describes the woman being placed in
There are no specific national guidelines (e.g. from the semi-lithotomy position and fetal head being pushed up
National Institute for Health and Care Excellence (NICE) or from the vagina by an assistant while the operating surgeon
from the RCOG) for performing CS at full dilatation applies upward traction on the baby. It is important that an
successfully and safely. However, intrapartum guidelines for experienced technician be employed to spread equal pressure
high-risk women are currently being developed. over the fetal head. Pressure at a single point is more likely to
cause fetal trauma. If possible, the head should be flexed to
Exposure narrow the diameter and ease delivery. The reverse breech
In the UK the most common incision for CS is transverse extraction or ‘pull’ method involves grasping one or both
abdominal.29 NICE advises that the Joel-Cohen incision – a fetal feet at the fundus of the uterus and applying steady
straight incision 3 cm above the pubic symphysis then blunt traction in the downward direction. Buttocks then follow and
opening of subsequent layers – should be performed. This flexion of the spine occurs at the thoracolumbar region.31
method has been shown to reduce levels of postoperative This allows more space to deliver the fetal head.
febrile morbidity and lead to shorter operating times.29 This Patwardhan’s method is described less commonly. This
recommendation is the same for second-stage procedures. involves delivery of both fetal shoulders through the incision
It is thought that when performing CS at full dilatation, a followed by the trunk, breech, and then finally lifting the
higher incision in the uterus may be necessary. This is head out of the pelvis.31 Other techniques such as flexion of
because the lower uterine segment is stretched, obscuring the the fetal head and rotation to reduce the diameter of the
anatomical landmarks that differentiate between vagina, presenting part and use of the non-dominant hand to exert
cervix and uterine body. A standard incision may risk steady pressure on the fetal head are described in
incising the bladder or the vagina, or may affect the integrity combination with different methods. However, there is no
of the cervix. Lower-segment incisions may also be at evidence assessing the efficacy of these techniques.
increased risk of tearing and be more difficult to repair. It is proposed that the ‘push’ method may be associated
However, this must be considered a good practice point, as with increased trauma to the lower uterine segment due to
no evidence can be found regarding accessing optimal manipulation of the fetal head. Additionally there is a
incision location. theoretical increased risk of infection due to contamination
from vaginal flora and risk of fetal scalp trauma.
Disimpacting the head Comparatively the ‘pull’ method may be associated with
The problem of disimpacting the fetus from the pelvis can be risk of extension to the uterine incision and neonatal trauma
confounded by ongoing uterine contractions. Syntocinon from traction of limbs.
infusions should be stopped as soon as the decision to The largest study randomised 108 women to the ‘push’
proceed with CS is made. Methods to relax the uterus have versus ‘pull’ method when presenting with obstructed labour
been considered to allow delivery of the baby. Several agents in Nigeria. The ‘push’ method was associated with
have been reported to be used as uterine relaxants in this significantly greater operative blood loss (1257 ml versus
circumstance. A systematic review of 13 randomised 898 ml, P < 0.01), extension of the uterine incision (30%
controlled trials found that the most commonly used agent, versus 11%, P < 0.05) and endometritis (57% versus 35%;
nitroglycerin, is not superior to placebo for uterine relaxation P < 0.05) compared to the ‘pull’ method. Additionally the
during CS.30 No evidence can be found demonstrating the ‘push’ method was associated with significantly worse mean
benefit of uterine relaxants for delivery of CS at full Apgar scores at 1 and 5 minutes, but there was no significant
dilatation. It is also important to note that use of uterine difference in neonatal injury (5.6% versus 7.4%) or neonatal
relaxants can impair postpartum uterine contraction and death (24% versus 13%) compared to the ‘pull’ method.32
therefore be likely to increase the risk of However, the study is clearly not powered, despite the high
postpartum haemorrhage. rates of adverse events, to detect important differences in
It is thought good practice to perform a vaginal examination neonatal outcome. Other small cohort studies comparing
in the operating theatre prior to surgery. Confirmation of fetal techniques also found greater rates of maternal infection
position and station can inform the method of delivery. It is (46.4% versus 5%, P < 0.05)33 and greater extension of

202 ª 2014 Royal College of Obstetricians and Gynaecologists

 Vousden et al.

uterine incision following the ‘push’ method compared to the Training

‘pull’ method (23% versus 2%, P < 0.05;22 50% versus 15%, Currently in the UK there are no formal training
P < 0.05;24 41% versus 5%, P < 0.05,25 respectively). A further programmes on the management of CS at full dilatation. A
small case–control study (n = 50) demonstrated a lower survey of 150 obstetric trainees demonstrated that 86% of
incidence of extension of the abdominal incision and less registrars and 94% of senior house officers agreed that
excessive bleeding following Patwardhan’s method compared training on how to deliver CS at full dilatation would be
to the ‘push’ method.34 useful. Additionally, two-thirds of registrars said that this
However, caution should be used with interpretation of training would increase confidence at managing a more
these studies, as there are significant limitations in study deeply impacted fetal head and therefore allow for trial of
designs. Apart from their small sample size, maternal operative vaginal delivery in more cases.38 The RCOG
characteristics, duration of second stage, prior attempt at recommends that a consultant should be present at every
operative vaginal delivery and experience of the operating CS at full dilatation.39 However, it is often an unpredictable
surgeon were either not documented or not adjusted for. emergency situation, so this is not always possible,
Additionally these studies demonstrate markedly higher particularly if complicated by fetal compromise ‘out of
incidence of maternal and neonatal morbidity and hours’. Therefore there may be a place for a structured
mortality compared with the previously mentioned larger protocol and specific drills that can be trialled for safe
European studies assessing morbidity following CS at full delivery, and best practice may be defined and incorporated
dilatation. This suggests that there must be significant into structured training programmes such as the ‘Managing
differences in patient cohort and obstetric management Obstetric Emergencies and Trauma’ course.
compared to current practice in many countries. Therefore, Simulation of emergency scenarios is used increasingly to
there is currently insufficient evidence to support the use of improve practical skills in a safe environment. Evidence
any one method. In addition, authors will inevitably have an relating to management of shoulder dystocia suggests that
agenda to promote their favoured technique, or the one they training with a simulation device improves manoeuvre
have researched, affecting publication bias. techniques, timeline of interventions and overall
Many other techniques are anecdotally described, and performance.40 Additionally, in this scenario, training with
include optimal positioning of the woman, such as the a mannequin can reduce the force used for successful
Whitmore position (modified lithotomy where thighs are delivery.41 Recently the first CS-at-full-dilatation simulator
moderately abducted and flexed to 135° from the trunk),35 has been developed, known as ‘Desperate Debra’.42 The
optimising the surgeon position, for example use of a stool or model can be used to simulate varying degrees of fetal head
low patient bed or use of non-dominant hand to apply an flexion, rotation and impaction into the pelvis. Research
even traction to disimpact the head. However, these have no evaluating the use of this device is currently underway to
established evidence base. assess whether the incorporation of this model into training
practice could be beneficial.
Medical devices
Various innovative devices have been described to aid delivery
Conclusion
at CS at full dilatation. The Foetal Disimpacting System
(Eurosurgical Ltd., Guildford, UK) consists of a silicone Caesarean sections during the second stage are increasing in
balloon that can be inserted through the vagina to rest under prevalence and are associated with significant long-term
the fetal head. It can then be inflated with saline in an attempt psychological and physical maternal morbidity. It is unclear
to elevate the fetal head. An unpublished pilot study of 30 how morbidity compares between operative vaginal deliveries
women in advanced labour reported elevation of 3 cm, as and CS at full dilatation, but both have significant problems
demonstrated by ultrasound, although detail of the study, such that require skill and knowledge to limit potential adverse
as whether there was any blinding, was not available.36 events. Both are likely to remain a frequent problem for
The C-snorkel is an anatomically curved tube with obstetricians in the foreseeable future with continuing
multiple ventilation ports. It can be inserted between the pressures to reduce elective CS rates. There is insufficient
vaginal wall and fetal head, and aeration through the ports evidence to recommend any specific technique for delivery of
can alleviate the vacuum between them, aiming to lessen the CS at full dilatation. Therefore this literature review
force required to disimpact the fetal head.37 Whereas the highlights the need for further research to determine the
theoretical benefits of both devices are appealing and both are optimal methods of delivery and their associated mortality
being marketed, neither has been demonstrated to be and morbidity. The nature of emergency deliveries will make
effective in any controlled study with meaningful it difficult to study different techniques, but their prevalence
endpoints. Nor is there available evidence of safety. and importance justifies investigation. In the meantime,

ª 2014 Royal College of Obstetricians and Gynaecologists 203

 Caesarean section at full dilatation: the current evidence

expert opinion on techniques and a consensus on 13 Murphy DJ, Liebling RE, Patel R, Verity L, Swingler R. Cohort study of
operative delivery in the second stage of labour and standard of obstetric
interpretation of well-designed, non-experimental, care. Br J Obset Gynaecol 2003;110:610–15.
descriptive studies are required in order to formulate 14 Bartholomew A, Corbett E, Kaikai E, King C, Nicholson S, Craggs A, et al.
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Data. London: NHS Litigation Authority; 2012 [http://www.nhsla.com/
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Staffing rotas need to allow quick access to senior clinicians at 2003;102:791–800.
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Increasing maternal body mass index and characteristics of the second
We have read and understood TOG policy on declaration of stage of labor. J Obstet Gynaecol 2011;118:1309–13.
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