Morbidity of Second Stage Cesarean Sections Before and After Provider Completion of Simulation Education at Regions Hospital
Conditions: Obstetric Labor Complications, Cesarean Section
Sponsor: HealthPartners Institute

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Morbidity of second stage cesarean sections before and after provider completion of 
simulation education at Regions Hospital  
 
NCT Number: NCT03387189    
 
Document Date: July 30, 2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1. Summary 
Cesarean deliveries performed during the second stage of labor can be very difficult due to 
impaction of the fetal head deep in the maternal pelvis and is associated with increased risk of 
both maternal and perinatal complications. On preliminary review, 16% of cesarean deliveries at 
Regions Hospital since 1/1/2017 were performed during the second stage, making this a 
common situation encountered by obstetricians. There is little existing data to inform 
management of deeply impacted fetal heads, therefore these situations can be difficult for 
surgeons and other healthcare staff when they arise. Our study aims to determine the morbidity 
of second stage cesarean deliveries before and after implementation of simulation protocols that 
address delivery of the impacted fetal head for Ob/gyn surgeons, nursing staff, and surgical 
technicians at Regions Hospital.  
 
2. Study Aims 
The primary aim of this study is to assess change in maternal and perinatal morbidity of second 
stage cesarean section during the time periods before and after simulation education for Ob/gyn 
surgeons, nursing staff, and surgical technicians at Regions Hospital compared to change in 
these same metrics during the same time frame at Methodist hospital, where the simulation 
education is not occurring. The simulation protocol is a Quality Improvement activity that 
addresses delivery of the impacted fetal head in second stage cesarean section.  
 
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Research question 1.1: Does implementation of a simulation protocol decrease a composite 
variable of maternal morbidity defined as a) extension of uterine incision, b) operative blood 
loss > 1000 mL c) requirement of transfusion, d) wound infection within 6 weeks, and d) 
endometritis within 6 weeks, at Regions Hospital compared to morbidity over the same time 
period at Methodist Hospital?  
• 
Research question 1.2: Does implementation of a simulation protocol decrease a composite 
variable of infant morbidity defined as a) 5 minute APGARs <7, b) NICU admission, c) 
umbilical cord arterial pH <7.1, and d) fetal injury of cesarean delivery during the second 
stage of labor at Regions Hospital compared to morbidity over the same time period at 
Methodist Hospital? 
 
The secondary aims of this study are to 1) assess provider confidence with delivery of the 
impacted fetal head before and after participating in simulation education and 2) assess change 
in maternal and perinatal morbidity of additional secondary outcomes, 3) assess the association 
of duration of second stage and maternal and perinatal outcomes.  
 
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Research question 2.1: Does Regions hospital provider and team confidence regarding 
delivery of impacted fetal head increase after participating in simulation education?  
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Research question 2.2: Does implementation of a simulation protocol that addresses 
delivery of the impacted fetal head decrease morbidity of other individual secondary 
outcomes (see variables table) of cesarean delivery during the second stage of labor at 
Regions Hospital compared to morbidity over the same time period at Methodist Hospital? 
• 
Research question 2.3: Is duration of second stage related to maternal and perinatal 
complications? 
 

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3. Background, Rationale, Significance  
Cesarean delivery during the second stage of labor has been shown to result a significant 
increase in maternal and perinatal complications, most often due to difficult delivery of the 
impacted fetal head [1,2,3,4]. The number of second stage cesarean deliveries is projected to 
increase for several reasons, particularly due to the overall decrease in operative vaginal 
deliveries and proposed lengthening of the permissible duration of the second stage of labor [3]. 
There have been few prospective studies that have compared the two traditional methods of 
delivery of an impacted fetal head, elevating the fetal head through the vagina (push method) or 
reverse breech extraction (pull method). These studies have suggested that the pull method is 
associated with fewer complications [3, 4, 5, 6]; however, there is no definitive, evidence based 
algorithm to guide management of these difficult deliveries. Because extraction of the fetal head 
during second stage deliveries can be an obstetric emergency, it necessitates team and 
provider education to facilitate anticipation, communication and timely management by all team 
members. Team simulations for obstetric emergencies have been shown to assist with provider 
comfort, improved clarity of thinking, and quicker action during emergency situations resulting in 
improved outcomes. Our study aims to show that simulation education for the entire obstetric 
team can decrease morbidity of difficult fetal head extraction associated with second stage 
cesarean deliveries and improve provider and nursing staff confidence regarding anticipation 
and management of this emergency.  
 
QI Project Description:  
The simulation education project is not being conducted primarily for the purpose of research, 
but is a department-wide educational activity and QI project that will be required for all OB staff 
physicians, residents, nursing staff, and surgical techs at Regions hospital that work in the Birth 
Center.  There are 120 providers or “birth center cesarean section delivery team members” at 
Regions hospital. Each staff person is require to attend one of the sessions. There will be 6 
simulation education events at Regions hospital with approximately 20 individuals attending 
each two hour session. A pre and post survey will be given at the simulation event. A 3rd survey 
6 months after the simulation event will also be distributed to assess team member confidence 
regarding second stage cesarean sections.  
 
The timeline of the simulation will be as follows: Pre simulation survey- 10 min, ACOG second 
stage cesarean section slide presentation- 20 min, practice with mannequins (separate for 
nursing and physician providers based on skill sets required)- 40 mins, combined second stage 
cesarean section scenario with whole team with debrief- 40 min, Post simulation survey- 10 min. 
This simulation will be based on a presentation given at the ACOG meeting in 2016. Simulations 
will be led by Dr. Kamalini Das, Dr. LeeAnn Hubbard, Dr. Larry Goldenberg, and Dr. Katelyn 
Bojan from mid October 2017 through mid-December 2017 in the simulation center at Regions 
hospital. 
 
All birth center team members will be notified regarding the simulation events by email and at 
staff meetings and will be required to attend 1 simulation event from mid-October-December 
2017.  Three additional simulation events will be offered during the project period for new Birth 
Center staff.   
 
4. Approach 
a. 
Study design: This study is an observational, time (pre vs. post simulation) by group  
(Regions vs. Methodist) design using a retrospective programmatic and manual chart review to 
evaluate the morbidity of second stage cesarean deliveries before and after implementation of 

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simulation education at Regions Hospital from July 2014 to June 2019. The same morbidity 
metrics will be gathered from patients at Methodist Hospital during the same pre and post-time 
periods to serve as a comparison group. Differential pre-post change in morbidity across 
patients at the two sites will serve as the key comparison. We will also assess staff confidence 
and change in self-confidence in the management of impacted fetal head using data from pre 
and post simulation Quality Improvement project surveys. 
 
b. 
Population 
i. Inclusion/Exclusion criteria:  
Patient inclusion: The patient study population includes all patients age 18-45 who 
underwent cesarean section during the second stage of labor (during the time period 
July 2014-June 2019 at Regions hospital and Methodist hospital). Second stage is 
defined as the time between complete cervical dilation and delivery of the infant. 
Exclusion criteria include patients who underwent cesarean section in second stage for 
malpresentations (i.e., breech and noncephalic presentations), patients who underwent 
cesarean section prior to 37 weeks gestation, and patients on the exclusion list for 
research. 
 
Members of the study team have verified the accuracy of this method of identifying 
cesarean section during the second stage of labor by cross-checking a Clarity pull of 
EMR data with chart audit for a random sample of 10 patients.  
 
Medical staff inclusion criteria: all 120 staff members (staff physicians, residents, nurses, 
surgical technicians) at Regions hospital who practice in the Birth center who underwent 
required simulation education regarding delivery of deeply impacted fetal heads during 
second stage cesarean section (50 physicians and 65 nurses and 5 techs) and 
completed the surveys as part of the QI simulation project. 
 
ii. Sample size 
Patients: A data pull conducted by an HP Institute RIIS programmer in September 2017 
indicated that there are 80 patients per year at Regions hospital having second stage 
cesarean sections and 80 patients per year at Methodist hospital having second stage 
cesarean sections. This study will gather data via programming and chart audit on the 
following counts of patients in these time period: 
 
A. July 1, 2014 – June 30, 2015 (80 Regions patients) 
B. July 1, 2015 – June 30, 2016 (80 Regions patients) 
C. July 1, 2016 – December 31, 2017 (120 Regions, 120 Methodist) - 18 mo PRE period 
D. January 1, 2018 – June 30, 2019 (120 Regions, 120 Methodist) - 18 mo POST period 
 
Different subsets of patients will be used for different research questions. For research 
questions 1.1, 1.2, 2.2 Group C above will serve as the pre-period patients and Group D 
for post-period patients. Thus, the total patient sample size for these research question 
is expected to be n=480. For research question 2.3, in addition to Groups C and D, we 
will also include utilize the 160 patients from Regions in Groups A and B for a sample 
size of 400 at Regions and 240 at Methodist (n=640 total).  
 
Medical staff sample size: The simulation center staff will survey 120 staff (50 
physicians, 65 nurses, and 5 techs) immediately before and after the required simulation 
education as part of an existing QI project. This QI project data will be used to address 

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research question 2.1. The simulation center and medical staff will also contact staff for 
a survey 6 months following the simulation for the QI project. With an expected response 
rate to the first and second surveys of 100% (because staff are surveyed at the 
simulation event), we will have n=120 complete first and second surveys. The response 
rate for the 6 month survey is expected to be 80%, yielding 96 surveys for this time 
period.  
 
c. Data collection process  
 
i. Data sources: Data sources for this study are: 1. Data pull from HP electronic medical 
record; 2. chart review; and 3. medical staff surveys from the simulation QI project.  
 
Patient sample: A Clarity pull of EMR data by the Institute RIIS programmer will gather 
many of the needed data elements. For data elements not readily available with a 
programmatic data pull, two University of Minnesota medical students along with Dr. 
Katelyn Bojan will conduct manual chart reviews of 640 patients to obtain the needed 
data elements (see outcomes table below).  
 
Staff sample: Staff-provided information from the simulation QI project. Pre and post 
electronic surveys of medical staff at the time of the simulation event as well as email 
surveys 6 months after the simulation event. Surveys will be administered using 
REDCap. These data collection activities are being done for a QI project, but this QI 
project data will be used to address research question 2.1 
 
ii. Process steps for identification of patients or records: 
Patient data: The study programmer (HP Institute RIIS programmer) will use the 
inclusion criteria specified earlier and used for the preliminary data counts to gather 
patient data on the expected 640 patients who are expected to be study-eligible at 
Regions and Methodist Hospitals in the pre and post-simulation periods. The data pull 
for patient identification will occur at multiple times to accommodate data needs for 
specific research questions. A chart review (described below) will be conducted to 
gather additional morbidity data. 
 
iii. Process steps for data acquisition 
Patient data: The Institute programmer will work with clinical study staff to operationally 
define all study data elements and will use a programmatic data pull to obtain all data 
elements from Clarity that can be obtained using this method. A Redcap database will 
be constructed by the study programmer containing the expected 640 patients, and will 
be used by chart auditors to manually chart audit data elements that cannot be obtained 
programmatically.  
 
Staff data: The study team will receive a data file of staff survey responses collected as 
part of the QI project. Surveys will be administered using REDCap or on paper at the 
time of the simulation. Simulation center staff will send survey data to the Institute study 
team via secure file transfer. 
 
d) Outcomes/endpoint and other variable definitions, and instruments used:  
A data source of “EMR” means that the data elements can be gathered by an Institute 
programmer using a programmatic data pull of Clarity (EMR) data. “Chart” means that the data 

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element will be manually abstracted from the EMR. The detailed listing of variables below will 
serve as the start of a data dictionary. The study programmer will add detailed codes to this 
document as the project progresses to document codes used to define each data element. The 
chart audit tool will be built in Redcap and does not yet exist. However, the listing of variables 
below with a data source of “chart” indicates which variables will be collected through the chart 
audit.  
 
Variable name 
Data 
Source 
Purpose 
Measurement 
scale 
Patient data 
Hospital at which second stage 
cesarean section occurred (Regions, 
Methodist) 
EMR 
Key grouping 
variable 
Binary 
Time period of cesarean section (pre or 
post Regions simulation) 
EMR 
Key grouping 
variable 
Binary 
Fetal station at time of delivery 
Chart 
Covariate 
Continuous 
Push vs pull method 
Chart 
Description 
Binary 
Use of instrumentation (vacuum or 
forceps) 
EMR 
Covariate 
Binary 
Person doing the head extraction (staff 
or resident) 
EMR 
Covariate 
Binary 
Maternal BMI 
EMR 
Description 
Continuous 
Fetal weight 
EMR 
Description 
Continuous  
Cesarean indication (maternal or fetal) 
EMR 
Description 
Binary 
Gestational age at the time of c/s 
EMR 
Description 
Continuous 
Parity 
Chart 
Description 
Continuous 
Length of second stage 
EMR 
Covariate 
Continuous 
Use of tocolytics at the time of c/s 
Chart 
Relationship to 
morbidity outcomes 
Binary 
Operative time 
Chart 
Secondary Study 
endpoint 
Continuous 

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Length of stay 
EMR 
Secondary Study 
endpoint 
Continuous 
Time from skin incision to delivery or 
uterine incision to delivery 
Chart 
Secondary Study 
endpoint 
Continuous 
Head pushed up from below prior to c/s 
Chart 
Relationship to 
morbidity outcomes 
Binary 
Previous c/s 
Chart 
Description 
Binary 
Extension of uterine incision 
Chart 
Component of 
Primary maternal 
study endpoint 
Binary 
Operative blood loss (codes as < 1000 
mL vs. > 1000 mL for primary endpoint) 
Chart 
Component of 
Primary maternal 
study endpoint 
Continuous, 
binary 
Number of blood transfusions (coded 
as 0 vs. any for primary endpoint) 
Chart 
Component of 
Primary maternal 
study endpoint 
Continuous, 
binary 
Endometritis within 6 weeks postpartum EMR 
Component of 
Primary maternal 
study endpoint 
Binary 
Wound infection within 6 weeks 
postpartum 
EMR 
Component of 
Primary maternal 
study endpoint 
Binary 
UTI during maternal admission 
EMR 
Secondary study 
endpoint 
Binary 
Bladder/ureteral/urethral injury 
Chart 
Secondary study 
endpoint 
Binary 
Type of uterine incision made 
Chart 
Description 
Continuous 
Maternal discharge Hemoglobin 
EMR 
Secondary study 
endpoint 
Continuous 
APGAR score at 5 minutes (coded as 
<7 vs. >=7 for primary endpoint) 
EMR 
Component of 
Primary infant study 
endpoint 
Continuous, 
binary 
APGAR score at 1 minute 
EMR 
Secondary study 
endpoint 
Continuous 

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NICU admission 
EMR 
Component of 
Primary infant study 
endpoint 
Binary 
Umbilical artery pH <7.1 
Chart 
Component of 
Primary infant study 
endpoint 
Binary 
Fetal injury (fractures, head injury, 
brachial plexus injury) 
EMR 
Component of 
Primary infant study 
endpoint 
Binary 
Fetal death 
EMR 
Secondary study 
endpoint 
Binary 
Fetal hyperbilirubinemia 
EMR 
Secondary study 
endpoint 
Binary 
Uterine incision to delivery time (also 
categorized as <1 minute >=1 minute) 
Chart 
Secondary study 
endpoint 
Continuous 
Maternal discharge hemoglobin 
Chart 
Secondary study 
endpoint 
Continuous 
Medical staff confidence in handling 
second stage cesarean sections 
QI Project 
Staff 
Survey 
Secondary study 
endpoint 
Continuous 
Medical staff perceptions of second 
stage cesarean sections 
QI Project 
Staff 
Survey 
Secondary study 
endpoint 
Continuous 
Medical staff knowledge of 
interventions & medications for second 
stage cesarean sections  
QI Project 
Staff 
Survey 
Secondary study 
endpoint 
Continuous 
Medical staff teamwork when handling 
second stage cesarean sections 
QI Project 
Staff 
Survey 
Secondary study 
endpoint 
Continuous 
 
Staff survey: The pre and post staff surveys are used for the QI project to assess staff 
perceptions of the required simulation training, and are included as the end of the narrative as 
appendices. These surveys use items developed for this project rather than existing tools. 
Surveys include a label to identify whether they are gathered before or after the simulation, and 
contain items such as confidence in handling second stage cesarean sections. 
 
f) Statistical analysis plan 
 
Descriptives (mean, standard deviation, proportion) and frequency distributions of all variables 
will computed and examined for distribution shape, outliers, missing data, and implausible data. 
Tables of descriptive statistics summarizing patients in both care systems (Regions, Methodist) 

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will be created. Because there are only 2 primary outcomes (both of which are composite 
variables), there will be no control for multiple testing. Inferential analysis of secondary 
endpoints will be considered exploratory with the known limitation that multiple testing could 
yield type 1 errors. Covariates in regression analysis will be specified a-priori on the basis of 
theory and when such covariates are unbalanced in comparison groups.  
 
Research question 1.1: Does the simulation protocol decrease a composite variable of maternal 
morbidity defined as a) extension of uterine incision, b) operative blood loss > 1000 mL, c) 
requirement of transfusion, d) wound infection within 6 weeks, and d) endometritis within 6 
weeks, at Regions Hospital compared to morbidity over the same time period at Methodist 
Hospital?  
 
Analytic sample: 480 maternal patients (120 Regions before/120 after simulation; 120 Methodist 
before/120 after simulation). Each sample of 120 is viewed as an independent sample.  
 
Analytic approach: Logistic regression will be used to predict the composite maternal morbidity 
endpoint (0/1) from hospital (Regions, Methodist), time (pre or post simulation), and their 
interaction. Covariates will be included if needed as described earlier. Model-based proportions, 
standard errors, and 95% CIs for each hospital for each time point, change over time, and 
differential change over time by hospital will be computed. A significant hospital * time 
interaction and pattern of effects showing more improvement over time in Regions than 
Methodist will support the underlying hypothesis of differential improvement over time favoring 
Regions and potentially due to the effects of the simulation. 
 
Research question 1.2: Does the simulation protocol decrease a composite variable of infant  
morbidity defined as a) 5 minute APGARs <7, b) NICU admission, c) umbilical cord arterial pH 
<7.1, and d) fetal injury, at Regions Hospital compared to morbidity over the same time period 
at Methodist Hospital?  
 
Analytic sample: 480 infant patients (120 Regions before/120 after simulation; 120 Methodist 
before/120 after simulation). Each sample of 120 is viewed as an independent sample.  
 
Analytic approach: Same as 1.1, but uses the endpoint of composite infant morbidity 
 
Research question 2.1: Does Regions hospital provider and team confidence regarding delivery 
of impacted fetal head increase after participating in simulation education?  
 
Analytic sample: The 120 staff completing the pre and post simulation surveys, and sample of 
80 completing the pre and 6 month surveys. This data is obtained from surveys from the QI 
project utilizing the required simulation training events. 
 
Analytic approach: Descriptive statistics (mean, proportion) and 95% CIs will be used to 
summarize staff survey items at each time point, and change from pre-simulation to immediately 
post-simulation, and pre-simulation to 6 month post-simulation. Plots over time of key survey 
items will illustrate staff reactions and perceptions over time. Simple paired-data analyses (e.g., 
paired t-tests, McNemar’s test) may be used to test change over time in key items or 
composites specified a-priori. Where possible, composites of multiple items will be summarized 
rather than individual items to reduce the number of comparisons and tests made.  
 

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Research question 2.2: Does implementation of the simulation protocol decrease morbidity of 
other individual secondary outcomes (see variables table) during the second stage of labor at 
Regions Hospital compared to morbidity over the same time period at Methodist Hospital? 
 
Analytic sample: 480 infant/maternal patients (120 Regions before/120 after simulation; 120 
Methodist before/120 after simulation). Each sample of 120 is viewed as an independent 
sample.  
 
Analytic approach: Same as 1.1, but dependent variables for these analyses will include the 
individual component items of the primary endpoints, and variables listed as “secondary 
endpoints” in the variable table. Due to the large number of tests conducted, these analyses will 
be viewed as more exploratory. 
 
Research question 2.4: Is duration of second stage related to maternal and perinatal 
complications? 
 
Analytic sample: 640 infant/maternal patients at Regions and Methodist seen June 2015-June 
2019.  
 
Analytic approach: Within each hospital (Regions, Methodist), duration of second stage will be 
stratified (<1 hour, 1-2 hrs, 2-3 hrs, 3-4 hrs, >4 hours). Individual maternal and infant endpoints 
in the variable table above will be summarized in terms of mean and proportion and 95% CIs 
within the strata. This analysis is considered descriptive and exploratory.  
 
g) Power analysis: Based on recent literature (Laughton, 2014; Vousden 2014, Kawakita 2017), 
the estimate of the composite maternal endpoint for research question 1.1 ranges from 20% (if 
all elements of the composite are completely overlapping) to 40% (if all elements of the 
composite are independent and additive). Making the simplifying assumptions that Regions and 
Methodist have the same morbidity in the pre-period, and that Methodist morbidity will not 
change from the pre to post-period, this study is powered at 80% (alphas=.05, 2-sided) to detect 
a difference in the Methodist and Regions maternal morbidity composite of 20% (Methodist) vs. 
8% (Regions); 30% vs. 15%, or 40% vs. 23%, using a logistic regression model. Similar 
assumptions could be applied to the infant composite endpoints. For the staff survey, the study 
is powered to detect a change in a continuous survey item (e.g., staff confidence in handling the 
procedure) from one time point to a later time point of 0.26 standard deviation units for the 
sample of n=120 (pre to post simulation) and 0.32 standard deviation units for the sample of 
n=96 (pre to 6 months, or post to 6 months).   
 
h) Strengths and limitations 
 
Strengths: Large N, broad availability of data elements, comparison group (Methodist Hospital) 
for more carefully assessing the effect of the QI project simulation training, enthusiastic buy-in 
by OB/GYN area in Regions, required QI project simulation training so all staff are exposed to 
simulation. 
 
Limitations: Lack of randomization, elements in chart might not be complete, two hospital 
systems might not be completely comparable, unknown baseline level of primary endpoints. 
 
5. Setting/Environment/Organizational feasibility 
The Regions Hospital birth center team delivers about 2400 babies a year. The staff and 
providers involved in cesarean sections are a relatively stable population. We do not have 

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providers from other groups performing cesarean sections. Residents are consistent over a 
period of 4 years. The Regions Hospital birth center has protocols for cesarean sections that are 
standard for all patients undergoing this procedure. The study outcomes should be easily 
compared without variations in cesarean section protocol. At Regions Hospital, team simulation 
events are organized with the simulation center staff throughout the year for other obstetrical 
emergencies such as shoulder dystocia, postpartum hemorrhage and hypertensive 
emergencies. We have the support of the birth center administration for this study 
 
6. Risks and Benefits 
There should not be risks to mothers, babies, and providers with this study. There is minimal 
risk to conducting this study; it is a retrospective, data-only study.  
Benefits may include: 
Knowledge of whether simulation training improved maternal and perinatal outcomes in patients 
with deeply impacted fetal head at cesarean section, staff and provider teamwork, and staff and 
provider morale.  
 
7. Data Confidentiality and Privacy 
Data will be stored on secure servers with limited access. Servers are in a physically secure 
location on campus and backed up nightly. Data will also be protected by username and 
password requirements.  
Data will be kept separately from patient identifiers. Identifiers will be destroyed at the earliest 
opportunity and data shared with the statistician will be completely de-identified. 
Patient identifiers will not be printed at any time during the study. 
 
8. Timeline 
Mid October-mid December 2017: QI project. Hold 6 simulation events for the impacted heat 
at cesarean section scenario. Each scenario will be 2 hours in length and mandatory for all 
Regions Hospital birth center providers, residents, nursing staff and techs. Will administer pre 
and posttest questionnaire before and after simulation event.  
December 2017- June 30th 2019: Study data extraction via Epic and chart review, from charts 
of patients undergoing second stage cesarean sections from pre and post simulation time 
periods. 
June 2018: QI project. Administer staff questionnaire 6 months after simulation event.  
June 2019: Data and statistical analysis and presentations and manuscript write up. 
 
9. Dissemination/Sharing Results/Integration and Impact 
Submit manuscript to peer reviewed journal 
Research poster at the GME event in May 2018 and 2019 
Resident research presentation May 2019 
Submission for presentation at ACOG in May of 2018 and 2019 
Birth center presentation at Regions Hospital 
Sharing results, simulation with Park Nicollet, Mercy Abbott and Stillwater Birth centers 
 
10. References 
1. McKelvey, A. et al Caesarean section in the second stage of labour: A retrospective 
review of obstetric setting and morbidity. Journal of Obstetrics and Gynaecology, April 
2010; 30(3):264-267 

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2. Pergialiotis, V, et al. First versus second stage C/S maternal and neonatal morbidity: a 
systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and 
Reproductive Biology October 2013 175(2014): 15-24 
3. Manning, Jennifer, M.D. et al. Delivery of an Impacted Fetal Head During Cesarean: A 
Literature Review and Proposed Management Algorithm. CME Review Article, 2015; 
7(11): 719-724 
4. Jeve, YB et al. Comparison of techniques used to deliver a deeply impacted fetal head 
at full dilation: a systematic review and meta-analysis. July 2015. DOI: 10.1111/1471-
0528.13593 
5. Bastani, Parvin et al. Comparison of neonatal and maternal outcomes associated with 
head-pushing and head-pulling methods for impacted fetal head extraction during 
cesarean delivery. International Journal of Gynecology and Obstetrics, May 2011; 
118(2012) 1-3 
6. Waterfall, H et al. Techniques for assisting difficult delivery at caesarean section. 
Cochrane Database of Systematic Reviews. 2016. 
DOI:10.1002/14651858.CD004944.pub3. 
7. Laughton SK et al. Neonatal and maternal outcomes with prolonged second stage labor. 
Obstet Gyncecol, July 2014; 124. 
8. Vousden NV et al. Cesarean section at full dilatation: incidence, impact, and current 
management. Obst & Gyn, 2014; 16: 199-205. 
9. Kawakita T, Landy HJ. Surgical site infections after cesarean delivery epidemiology, 
prevention, and treatment. Maternal Health, Neonatology, and Perinatology (2017) 3:12 
DOI 10.1186/s40748-017-0051-3