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Research Article | Volume 11 Issue 8 (August, 2025) | Pages 117 - 124
Comparison of Maternal and Foetal Outcome of Caesarean Sections in First Stage versus Second Stage of Labor
 ,
 ,
1
Senior Resident, MBBS, MS, Department of Obstetrics and Gynaecology, R. G. Kar Medical College & Hospital, Kolkata, West Bengal 700004
2
Associate professor, MBBS, DGO, MS, Department of Obstetrics and Gynaecology, R. G. Kar Medical College & Hospital, Kolkata, West Bengal 700004
3
3Senior Resident, MBBS, MS, Department of Obstetrics and Gynaecology, Nil Ratan Sircar Medical College and Hospital, West Bengal, Kolkata-700014
Under a Creative Commons license
Open Access
Received
June 20, 2025
Revised
July 5, 2025
Accepted
July 23, 2025
Published
Aug. 6, 2025
Abstract

Background: Caesarean section (CS) performed in the second stage of labor has been associated with greater maternal and neonatal risks compared to CS in the first stage. With rising rates of second stage CS in modern obstetric practice, it is crucial to evaluate and compare the outcomes to guide clinical decisions and improve perinatal care. Aims: This study aims to compare fetomaternal outcomes of caesarean sections performed in the first versus second stage of labour by examining the rising incidence of second-stage caesareans, evaluating related maternal and neonatal risks, and reviewing current evidence to suggest best practices and highlight the need for further research into predictive models and strategies to enhance surgical safety and long-term outcomes. Materials & methods: This observational prospective analytical study was conducted over 18 months (February 2020–July 2021) in the Department of Obstetrics and Gynaecology at R.G. Kar Medical College and Hospital, Kolkata. It included 90 antenatal mothers in labour who underwent caesarean section—45 in the first stage of labour (Group A) and 45 in the second stage (Group B)—according to the study’s inclusion criteria. The hospital, a tertiary care centre, performs about 5000 emergency caesarean sections annually. Result: The study compared maternal and neonatal outcomes of caesarean sections performed in the first stage of labour (Group-A) versus the second stage (Group-B). Baseline characteristics—such as age, parity, religion, gestational age, and birth weight—were similar between groups with no significant differences. However, indications for caesarean differed: fetal distress and non-progress of labour were more common in Group-A, while deep transverse arrest and cephalopelvic disproportion were more frequent in Group-B (P=1.121). Intraoperative complications—including haemorrhage >1000 ml, uterine incision extension, and bladder injury—were significantly higher in Group-B. Postoperative complications like wound infection and prolonged hospital stay were also more common in Group-B. Regarding neonatal outcomes, adverse events such as APGAR <7 at 5 minutes, higher NICU admission rates, and longer NICU stay were significantly more frequent in Group-B. Conclusion: In conclusion, the study demonstrated that while baseline maternal and neonatal characteristics were comparable between caesarean sections performed in the first and second stages of labour, the outcomes varied notably. Caesarean sections in the second stage were associated with significantly higher rates of intraoperative complications such as excessive haemorrhage, uterine incision extensions, and bladder injuries. Postoperative complications, including wound infection, wound dehiscence, and prolonged hospital stay, were also more frequent in this group. Moreover, neonatal outcomes were less favourable in the second stage group, with a greater proportion of babies exhibiting lower APGAR scores at five minutes, increased need for NICU admission, and longer NICU stays, underscoring the elevated risks associated with second stage caesarean sections

Keywords
INTRODUCTION

Caesarean section (CS) has become one of the most common surgical procedures worldwide, playing a critical role in reducing maternal and perinatal morbidity and mortality when appropriately indicated. Globally, the incidence of CS has risen significantly over recent decades, from about 12% in 2000 to over 21% in 2015, with considerable regional variations depending on obstetric practices, resources, and maternal preferences [1,2]. While CS is often life-saving, it carries inherent maternal and neonatal risks, which may differ depending on the stage of labor at which it is performed [3]. The distinction between CS performed in the first stage of labor—when the cervix is dilating—and those performed in the second stage—after full cervical dilatation and during descent of the fetal head—has profound implications for both maternal and fetal outcomes.

 

Second-stage CSs are usually technically more challenging due to the deeply engaged fetal head, edematous lower uterine segment, and reduced uterine contractility, which can increase operative time, blood loss, and complications such as extension of uterine incisions and bladder injury [4,5]. Several studies have shown that maternal morbidity—including postpartum hemorrhage, need for blood transfusion, and visceral injuries—is significantly higher in CS performed during the second stage compared to the first stage [6]. Furthermore, the decision-to-delivery interval in second-stage CSs is often prolonged, which may further contribute to adverse fetal outcomes [7].

For the fetus, delivery during the second stage is associated with increased risks of birth asphyxia, lower Apgar scores, and admission to neonatal intensive care units (NICU) [8]. Difficult extraction of the deeply impacted fetal head may necessitate the use of additional techniques, such as the reverse breech extraction or the push method, which carry their own risks, including trauma and intracranial hemorrhage [9]. Neonatal complications, including scalp injuries, cephalohematomas, and brachial plexus injuries, have also been reported more frequently in second-stage CSs [10].

The rise in CS rates, especially those conducted in the second stage of labor, has raised significant concern within the obstetric community regarding the need for timely and appropriate decision-making during labor. Timely identification of labor dystocia, failed instrumental delivery, or fetal distress is critical to prevent the need for second-stage CSs, which are known to be associated with worse maternal and neonatal outcomes [3,6]. Furthermore, the increased incidence of CS in the second stage poses important questions regarding training and preparedness of obstetric teams to handle these technically demanding surgeries safely.

 

This study aims to compare feto maternal outcomes of caesarean sections performed in the first versus second stage of labour by exploring the reasons behind the increasing rates of second-stage caesareans, analysing the associated maternal and neonatal risks, and reviewing current evidence to outline best practices and identify areas requiring further research, such as predictive models and strategies to improve surgical safety and long-term outcomes.

MATERIALS AND METHODS

Study Design: Observational prospective analytical study.

Study Settings: Hospital based study in R.G.Kar Medical College and Hospital among the patients who are in labour and undergoing caesarean section in the department of Obstetrics and Gynaecology

Place of Study: Department of Obstetrics and Gynaecology, RG KAR Medical College & Hospital, Kolkata

Period of Study: 18 Months from February 2020 to July 2021

 

Study Population: According to inclusion criteria of our study, all antenatal mother, who are in labour, admitted through emergency or out door, undergoing caesarean section either in first or second stage of labour will be our study population. In our institution almost 5ooo emergency caesarean sections performed during labour.

Sample Size: The total sample size will be 90 participants (45 in Group A and 45 in Group B).

 

Inclusion Criteria

  • Singleton pregnancy, irrespective of parity
  • Period of gestation ≥ 37 weeks
  • Cephalic presentation
  • No previous lower segment caesarean section (LSCS)

 

Exclusion Criteria

  • Multiple pregnancy
  • Preterm deliveries
  • Malpresentations
  • Medical complications associated with pregnancy
  • Previous history of LSCS

 

Study Variables

Maternal demographic and obstetric variables:

  1. Age
  2. Parity
  3. Gestational age
  4. Onset of labour
  5. Duration of first stage of labour
  6. Augmentation of labour with oxytocin
  7. Duration of second stage of labour
  8. Indications for caesarean section
  9. Duration of operation

Intraoperative variables:

  1. Intraoperative complications:
  • Excessive haemorrhage
  • Uterine incision extension
  • Urinary bladder injury
  • Requirement of obstetric hysterectomy

Postoperative maternal outcomes:

  1. Postoperative complications:
  • Postpartum haemorrhage
  • Wound infection and/or dehiscence
  • Postoperative fever
  • Rectus sheath haematoma
  • Requirement of high dependency unit (HDU) care
  1. Length of stay in HDU and total hospital stay

Neonatal outcomes:

  1. Birth weight
  2. Apgar scores at 1 minute and 5 minutes
  3. Requirement of NICU admission
  4. Requirement of mechanical ventilation
  5. Neonatal sepsis
  6. Neonatal jaundice
  7. Length of stay in NICU and total hospital stay
  8. Neonatal death

 

Statistical Analysis:-

For statistical analysis, data were initially entered into a Microsoft Excel spreadsheet and then analysed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5). Numerical variables were summarized using means and standard deviations, while Data were entered into Excel and analysed using SPSS and GraphPad Prism. Numerical variables were summarized using means and standard deviations, while categorical variables were described with counts and percentages. Two-sample t-tests were used to compare independent groups, while paired t-tests accounted for correlations in paired data. Chi-square tests (including Fisher’s exact test for small sample sizes) were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

 

RESULTS

Table: 1. Baseline Demographic and Obstetric Characteristics of Study Groups

Demographic and Obstetric Characteristics

Group-A (n=45) (%)

Group-B (n=45) (%)

P value

Age in years

<20

4(8.9%)

4(8.9%)

0.7285

21-30

36(80%)

38(84.5%)

31-40

4(8.9%)

2(4.4%)

>40

1(2.2%)

1(2.2%)

Parity

Primipara

25(55.56%)

30(66.7%)

0.28

Multipara

20(44.44%)

15(33.3%)

Religion

Hindu

7 (15.6%)

5 (11.1%)

0.54

Muslim

38 (84.4%)

40 (88.9%)

Gestational age (In weeks)

37-39

28(62.2%)

29(64.4%)

0.1947

≥40

17(37.8%)

16(35.6%)

 

 

Table: 2. Comparison of Primary Indications Leading to Caesarean Section between Study Groups

Indications of Caesarean section

Group-A (n=45) (%)

Group-B (n=45) (%)

P value

Non progress of labor

17 (37.8%)

1 (2.2%)

1.121

CPD

4 (8.9%)

16 (35.6%)

DTA

5 (11.1%)

23 (51.1%)

FD

19 (42.2%)

3 (6.7%)

Failed instrumental delivery

0 (0%)

2 (4.4%)

Table: 3. Distribution of Intraoperative, Postoperative Maternal Complications and Neonatal Outcomes among Study Groups

Maternal Complications

Group-A (n=45) (%)

Group-B (n=45) (%)

P value

Intraoperative

Haemorrhage >1000 ML

Yes

5 (11.1%)

15 (33.3%)

0.011

No

40 (88.9%)

30 (66.7%)

Uterine incision extension

Yes

1 (2.2%)

8 (17.8%)

0.013

No

44 (97.8%)

37 (82.2%)

Urinary bladder injury

Yes

1 (2.2%)

7 (15.5%)

0.026

No

44 (97.8%)

38 (84.5%)

PPH

Yes

3 (6.7%)

2 (4.4%)

0.645

No

42 (93.3%)

43 (95.6%)

Post-Operative

Postoperative wound infection & dehiscence

Yes

1 (2.2%)

6 (13.3%)

0.049

No

44 (97.8%)

39 (86.7%)

Requirement of HDU

Yes

0 (0%)

2 (4.4%)

0.1526

No

45 (100%)

43 (95.6%)

Length of hospital stay >7 days

Yes

6 (13.3%)

21 (46.7%)

0.0005

No

39 (86.7%)

24 (53.3%)

Table: 4. Distribution of Birth Weight, APGAR Scores, and NICU Admission among Study Groups

Parameter

Group A (n=45) (%)

Group B (n=45) (%)

P value

Birth weight (in kg)

<2.5

3(6.7%)

1(2.2%)

0.3899

2.5-3.5

29(64.4%)

27(60%)

>3.5

13(28.9%)

17(37.8%)

APGAR at 5 min <7

Yes

1(2.2%)

6(13.3%)

0.049

No

44(97.8%)

39(86.7%)

Requirement of NICU

Yes

3(6.6%)

10(22.2%)

0.036

No

42(93.4%)

35(77.8%)

Length of NICU stay (in days)

01-03

31(68.9%)

18(40%)

0.0057

>3

14(31.1%)

27(60%)

The distribution of age among women in Group-A and Group-B was comparable, with the majority in the 21–30 years age group (80% vs. 84.5%, respectively). Only a small proportion of patients in each group were younger than 20 years (8.9% each) or older than 40 years (2.2% each). The difference in age distribution between the groups was not statistically significant (P=0.7285). Regarding parity, primipara were slightly more in Group-B (66.7%) compared to Group-A (55.56%), while multipara constituted 44.44% in Group-A and 33.3% in Group-B; this difference was also statistically non-significant (P=0.28). The majority of participants in both groups were Muslim (84.4% in Group-A and 88.9% in Group-B), with Hindu patients representing a smaller proportion (15.6% and 11.1%, respectively), and this difference was not significant (P=0.54). Most deliveries occurred between 37–39 weeks of gestation (62.2% in Group-A and 64.4% in Group-B), while the remaining were at ≥40 weeks; again, the difference was statistically non-significant (P=0.1947).

The indications for caesarean section varied significantly between Group-A and Group-B. In Group-A, the most common indication was fetal distress (FD), accounting for 42.2% of cases, whereas in Group-B it was deep transverse arrest (DTA), observed in 51.1% of cases. Cephalopelvic disproportion (CPD) was noted more frequently in Group-B (35.6%) compared to Group-A (8.9%). Non-progress of labor (NPOL) was the indication in 37.8% of patients in Group-A, but only 2.2% in Group-B. Failed instrumental delivery accounted for 4.4% of cases in Group-B and none in Group-A. The difference in indications between the two groups was statistically significant (P=1.121). These findings suggest that fetal distress and non-progress of labor were the leading indications in the first stage (Group-A), whereas deep transverse arrest and CPD were more frequent indications in the second stage (Group-B).

Intraoperative complications were significantly more frequent in Group-B compared to Group-A. Haemorrhage exceeding 1000 ml occurred in 33.3% of patients in Group-B, significantly higher than in Group-A (11.1%) (P=0.011). Uterine incision extension was noted in 17.8% of Group-B cases versus only 2.2% in Group-A (P=0.013). Urinary bladder injury was also more common in Group-B (15.5%) compared to Group-A (2.2%) (P=0.026). The incidence of postpartum haemorrhage (PPH) did not differ significantly between the groups (6.7% in Group-A vs. 4.4% in Group-B; P=0.645).

Regarding postoperative complications, wound infection and dehiscence were more frequent in Group-B (13.3%) than in Group-A (2.2%), and this difference was statistically significant (P=0.049). Requirement for high dependency unit (HDU) care was seen only in Group-B (4.4%), though this was not statistically significant (P=0.1526). Notably, prolonged hospital stay (>7 days) was significantly higher in Group-B (46.7%) compared to Group-A (13.3%) (P=0.0005).

The distribution of birth weight was similar between the two groups, with the majority of neonates weighing between 2.5–3.5 kg (64.4% in Group-A and 60% in Group-B), and this difference was not statistically significant (P=0.3899). However, adverse neonatal outcomes were significantly more common in Group-B. The proportion of new-borns with an APGAR score <7 at 5 minutes was higher in Group-B (13.3%) compared to Group-A (2.2%), which was statistically significant (P=0.049). The need for NICU admission was also significantly greater in Group-B (22.2%) than in Group-A (6.6%) (P=0.036). Furthermore, a longer duration of NICU stay (>3 days) was observed in 60% of neonates in Group-B, compared to 31.1% in Group-A, and this difference was statistically significant (P=0.0057).

DISCUSSION

In this study, the demographic characteristics between women undergoing caesarean section in the first stage (Group-A) and second stage (Group-B) of labour were comparable, aligning with observations by Khedkar et al. (2017), who also reported a predominance of patients aged 21–30 years and a similar distribution of parity in both groups [11]. The higher proportion of primiparas undergoing second-stage caesarean section in our study (66.7% in Group-B vs. 55.6% in Group-A) is consistent with findings by Sunanda et al. (2021), who emphasized that inadequate pelvic capacity and poor maternal expulsive efforts in primigravidas often necessitate second-stage intervention [12].

 

The indications for caesarean section differed significantly between groups, reflecting the classical shift described in literature. In Group-A, fetal distress (42.2%) and non-progress of labour (37.8%) were leading indications, whereas deep transverse arrest (51.1%) and cephalopelvic disproportion (35.6%) predominated in Group-B. This pattern parallels findings from Leung et al. (2001) and Allen et al. (2006), where deep transverse arrest and malpositions were major contributors to second-stage caesareans [13,14]. The occurrence of failed instrumental delivery exclusively in Group-B also resonates with the report by Koyyalamudi et al. (2017), highlighting that instrumental delivery failures frequently escalate to operative intervention late in labour [15].

 

Our results demonstrated significantly higher intraoperative complications in Group-B, notably haemorrhage >1000 ml (33.3% vs. 11.1%), uterine incision extension (17.8% vs. 2.2%), and bladder injury (15.5% vs. 2.2%). These findings align with those of Allen et al. (2006), who reported an increased risk of traumatic injury and haemorrhage due to deeply impacted fetal head and reduced uterine space in second-stage caesareans [14]. Similar complication rates were documented by Alexander et al. (2007), who emphasized technical challenges in these cases [16]. Although the incidence of postpartum haemorrhage did not differ significantly, the absolute numbers were higher in Group-B, supporting observations by Koyyalamudi et al. (2017) [15].

 

Regarding postoperative complications, wound infection and dehiscence were significantly more frequent in Group-B (13.3% vs. 2.2%), consistent with Gupta et al. (2018), who attributed this to prolonged operative time, increased blood loss, and repeated handling of tissues [17]. The requirement for HDU care, though higher in Group-B (4.4%), did not reach statistical significance, mirroring similar trends reported by Sunanda et al. (2021) [12]. Notably, prolonged hospital stay (>7 days) was significantly higher in Group-B (46.7% vs. 13.3%), which parallels the findings of Alexander et al. (2007) and reflects the impact of complex surgeries and complications [16].

 

The neonatal outcomes further highlighted the risks associated with second-stage caesareans. A significantly higher proportion of neonates had APGAR scores <7 at 5 minutes in Group-B (13.3% vs. 2.2%), aligning with Khedkar et al. (2017) and Allen et al. (2006), who reported compromised neonatal adaptation due to prolonged labour and operative difficulties [11,14]. NICU admission was also significantly greater in Group-B (22.2% vs. 6.6%), as was longer NICU stay (>3 days; 60% vs. 31.1%). Similar neonatal morbidity was observed by Gupta et al. (2018), emphasizing the impact of fetal head moulding, distress, and delivery trauma [17].

 

Overall, our study underscores that second-stage caesarean section is associated with significantly higher maternal and neonatal morbidity compared to first-stage caesarean, in line with the cumulative evidence from several studies [20]. These findings highlight the importance of timely decision-making, appropriate use of instrumental delivery, and training in operative techniques such as the Patwardhan or reverse breech methods to mitigate maternal and neonatal risks, as advocated by Leung et al. (2001) and Goucher et al. (2018) [13,18]. Future multicentre studies could further delineate strategies to optimise outcomes.

CONCLUSION

We conclude that, the present study highlights that caesarean sections performed during the second stage of labour were associated with distinctly different indications and a higher risk of adverse fetomaternal outcomes compared to those performed in the first stage. While demographic characteristics such as age, parity, religion, gestational age, and birth weight distribution were largely comparable between the two groups, the clinical picture diverged significantly at the time of intervention. In the first stage, fetal distress and non-progress of labour were the most common indications, whereas deep transverse arrest and cephalopelvic disproportion predominated in the second stage.

 

Notably, intraoperative complications—including excessive haemorrhage, uterine incision extensions, and bladder injuries—were considerably more frequent when caesarean was performed at full cervical dilatation. Postoperative complications such as wound infection, wound dehiscence, and prolonged hospital stay were also observed more often in these patients. From a neonatal perspective, infants delivered by second-stage caesarean were more likely to have lower APGAR scores at five minutes, greater need for NICU admission, and longer duration of NICU stay, reflecting higher neonatal morbidity.

 

Overall, these findings underscore the increased maternal and neonatal risks associated with caesarean section in the second stage of labour and reinforce the need for careful intrapartum monitoring, timely decision-making, and meticulous surgical technique to mitigate these complications.

REFERENCES
  1. Betrán AP, et al. The increasing trend in caesarean section rates: global, regional and national estimates: 1990–2014. PLOS ONE. 2016;11(2):e0148343.
  2. Boerma T, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341–1348.
  3. Allen VM, et al. Maternal morbidity associated with cesarean delivery without labor compared with induction of labor at term. Obstet Gynecol. 2006;108(2):286–294.
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  11. Khedkar IA, Suryawanshi P, Shrivastava A, et al. Maternal and perinatal outcome in caesarean sections done in second stage of labour. Int J Reprod Contracept Obstet Gynecol. 2017;6(2):516–520.
  12. Sunanda GS, Kumaraswamy RC. Maternal and fetal outcomes in caesarean sections done in second stage of labour. Int J Reprod Contracept Obstet Gynecol. 2021;10(2):687–692.
  13. Leung TY, Chung TKH, Rogers MS, Sahota DS. Delivery of the deeply impacted fetal head during caesarean section at full cervical dilatation using the reverse breech extraction technique. BJOG. 2001;108(7):730–734.
  14. Allen VM, O’Connell CM, Baskett TF. Maternal and perinatal morbidity of caesarean delivery at full cervical dilatation compared with caesarean delivery in the first stage of labour. BJOG. 2006;113(3): 402–407.
  15. Koyyalamudi V, Sidhu G, Cornett EM, et al. Second-stage cesarean delivery: Challenges and management strategies. Int J Womens Health. 2017;9:539–551.
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  17. Gupta M, Meena S, Verma RK, et al. Maternal and fetal outcome in cesarean section during second stage of labor. Int J Reprod Contracept Obstet Gynecol. 2018;7(5):1847–1851.
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