**2. Cesarean section in environments with adequate resources**

#### **2.1 Risks in full dilation cesarean section with absolute dystocia**

The risks of a full dilation cesarean section appear to be less important when there is the availability of an operating room and the necessary support services to perform the intervention. While the risks are somehow lowered in this scenario, all the associated complications should be anticipated. A large retrospective cohort study conducted in Nova Scotia [1] assessed 55,273 births, comprising 549 full dilation cesarean sections. Authors proved that women who underwent a full dilation C-section were more likely to experience intraoperative trauma and perinatal asphyxiation compared to the ones who underwent a cesarean section during the first stage of labor (OR, 2.57; 95% CI, 1.71–3.88 and OR, 1.5; 95% CI, 1.06–2.14). These results confirm that, even in high-level hospital settings, maternal and neonatal outcomes can be adversely affected by prolonged labor, leading to a full dilation cesarean section. Another study involved 627 singleton pregnancies in nulliparous women who underwent an emergency cesarean section in the UK; of these, 199 (18.9%) had a full dilatation cesarean section [2]. Intraoperative complications and blood transfusions were more likely to occur in women undergoing a full dilation cesarean section (OR, 4.6; 95% CI, 2.7–7.9 and OR, 2.9; 95% CI, 1.5–5.6). Apart from that, there were no differences in terms of the incidence of new hospitalization, hospitalization longer than 5 days, or perinatal morbidity between the two groups. Another small retrospective study conducted at Singapore on 110 emergency full dilation cesarean sections showed no statistically significant adverse maternal or fetal outcomes [3]. It is not uncommon for the bladder to be injured or lacerated during a cesarean section for protracted or obstructed labor. Once the lesion is recognized, the bladder can be fixed with a two-layer closure; if the ureters or the bladder trine is damaged, urological consultation has to be performed, and if it is not available, the patient should be immediately transferred to a center where it can be done. After the repair of the bladder injury, a urinary catheter should be left in for at least 7–10 days.

#### **2.2 Rupture of the uterus**

Rupture of the uterus during labor has dramatic consequences for both the mother and the fetus; following the uterine rupture, the fetus passes into the abdominal cavity with low chances of survival unless rapid intervention is performed. This situation is often accompanied by some degree of placental abruption. If the patient is admitted to a high-level hospital, early identification of the rupture—one of the first signs is abnormal fetal heart rate on CTG [4]—and delivery within 18 minutes [5] by laparotomy can prevent fetal death and the onset of neurological complications. Risks of hypoxic ischemic encephalopathy and perinatal death with uterus rupture stand at 6.8% (1.8–10.6%) and 1.8% (0.0-4%,2%), respectively [6, 7]. Women who decide to undergo a TOLAC (trial of labor after cesarean) should be informed about the risk of uterine rupture during labor; for women with a previous Pfannenstiel incision, this risk is about 1% and increases between 4 and 9% for those with a classic scar [8]. Uterine rupture rarely occurs in women who have never undergone full-thickness uterine surgery, especially in a low-resource environment, after prolonged obstructed labor and increased uterine contractions [9].
