**2. Complications associated with second stage cesarean section**

Incidence of cesarean section is increasing throughout the world, so is the second stage cesarean section. There is a steady increase in the incidence of Cesarean Section. A 10-year study showed a rising incidence of Cesarean section at full dilatation, and currently, the incidence of second stage Cesarean section is around 2% [1]. Unexpected complications, like unsatisfactory progress or fetal distress, may occur in the second stage of labour. Second stage section is usually done for CPD or fetal distress. With fewer Obstetricians not using assisted vaginal deliveries, the incidence of the second stage is increasing. Management of delay in the second stage requires a lot of skill and judgment. To deliver a head which is deeply impacted in the pelvis is difficult. Opting for a vaginal delivery with assistance requires considerable skill and judgment. In general, fewer people attempt assisted vaginal deliveries now. More and more cases are taken for a section rather than difficult assisted deliveries. Within the national maternity hospital in Dublin in a center with more than 9000 deliveries per year, While the cesarean section incidence has increased from 18.3% to 23.5% from 2005 to 2014, there is a sharp decline in assisted vaginal deliveries from 14–11% [2]. In the year 2014, there were 8000-second stage cesarean section in the UK [3].

Second stage Cesarean sections are associated with more complications than first stage cesarean sections. Cesarean section done at full dilatation of cervix with head deeply engaged in the pelvis is a potential risk factor for maternal and fetal injury. Second stage cesarean section is associated with more genital trauma and perinatal morbidity. Second stage cesarean sections can be related to trauma, bleeding, peripartum Hysterectomy. Analysis of second stage complications ere studied by V M Allen et al. in a study in 2005. They looked at the difficulties associated with second stage sections over five years. A total of 549 cases of second stage sections. Incidence of intraoperative trauma was 6.4%, and two patients underwent peripartum Hysterectomy. 57(4.7%) of cases had early postpartum bleeding. 9(1.1%) subjects had postoperative febrile morbidity. The relative risk of maternal trauma is 2.6, and perinatal Asphyxia was 1.5 in the above study by V M Allen at al [4]. In a study by Murphy et al. Second stage sections were associated with more chances of bleeding. Out of 209 women who underwent section in the second stage, 20(10%) had bleeding more than 1000 mL. Almost 50 (24%) of cases had extension of the cesarean wound after the second stage section [5].

Newborn injuries are more common following assisted vaginal deliveries than sections. Incidence of newborn trauma was (22% of 184 deliveries in Cesarean section versus 9% of 209 assisted vaginal deliveries). Severe fetal injuries, like Brachial plexus trauma, was also more common following operative vaginal deliveries [4]. Operative trauma like intracranial hemorrhage is also more common following operative vaginal deliveries. The incidence of intracranial bleeding was 1 of 860 infants delivered by vacuum extraction, 1 of 664 delivered using forceps and 1 of 907 delivered by cesarean section during labour [6]. Hence avoiding a difficult assisted vaginal delivery will decrease the incidence of severe fetal trauma. However, neonatal complications like Asphyxia and intensive care admissions are more common in second stage sections. Reduced Apgar scores and lower umbilical artery pH was 11 per cent in women who underwent cesarean section at full dilatation versus 6% among women who underwent vaginal assisted delivery [4]. However, this may be due to prolonged labour and may not be directly related to delivery mode. There was no significant neurodevelopmental delay between babies delivered by assisted vaginal delivery and Cesarean section when followed up for five years. The overall incidence of neurodevelopmental delay was low [7].

Since the Cesarean section at full dilation is associated with increased maternal and neonatal morbidity every attempt should be made to reduce the second stage cesarean section. Judicious use of Oxytocin and monitoring of labour by partogram may reduce the incidence of second-stage cesarean section. A senior consultant obstetrician's presence can result in more vaginal deliveries and can reduce cesarean section at full dilatation [8]. Instrumental delivery is more likely to fail in occiput posterior position than anterior positions. Hence a careful vaginal examination and use of ultrasound should determine the position of the head before attempting an instrumental delivery [9].
