No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Neonatal respiratory morbidity and mode of delivery at term: Influence of timing of elective caesarean section
Abstract
Objective: To establish whether the timing of delivery between 37 and 42 weeks gestation influences neonatal respiratory outcome and thus provide information which can be used to aid planning of elective delivery at term. Design: All cases of respiratory distress syndrome or transient tachypnoea at term requiring admission to the neonatal intensive care unit were recorded prospectively for nine years. Setting: Rosie Maternity Hospital, Cambridge Subjects: During this time 33,289 deliveries occurred at or after 37 weeks of gestation. Main outcome measures: This information enabled calculation of the relative risk of respiratory morbidity for respiratory distress syndrome or transient tachypnoea in relation to mode of delivery and onset of parturition for each week of gestation at term. Results: The incidence of respiratory distress syndrome at term was 2.2/1000 deliveries (95 % CI; 1.7-2.7). The incidence of transient tachypnoea was 5.7/1000 deliveries (95 % CI; 4.9-6.5). The incidence of respiratory morbidity was significantly higher for the group delivered by caesarean section before the onset of labour (35.5/1000) compared with caesarean section during labour (12.2/1000) (odds ratio, 2.9; 95% CI 1.9-4.4; P < 0.001), and compared with vaginal delivery (5.3/1000) (odds ratio, 6.8; 95 % CI 5.2-8.9; P < 0.001). The relative risk of neonatal respiratory morbidity for delivery by caesarean section before the onset of labour during the week 37+0 to 37+6 compared with the week 38+0 to 38+6 was 1.74 (95 % CI 1.1-2.8; P < 0.02) and during the week 38+0 to 38+6 compared with the week 39+0 to 39+6 was 2.4 (95 % CI 1.2-4.8; P < 0.02). Conclusions: A significant reduction in neonatal respiratory morbidity would be obtained if elective caesarean section was performed in the week 39+0 to 39+6 of pregnancy.
... Epidemiology TTN, the commonest neonatal respiratory disorder, affects approximately 7-10% of the neonatal population [3], with an incidence of new cases twice that of respiratory distress syndrome (RDS) [4]. While these figures are well known, it is difficult to detail the epidemiology of TTN. ...
... The incidence of TTN decreases with gestational age and is halved from 33 to 36 weeks' gestation [6]. Caesarean section, particularly if performed before the onset of labour, increases the incidence of TTN and the type of delivery and gestational age have an interaction effect [4]. Admission to the neonatal intensive care unit (NICU) after caesarean section is twice as common in early-term as in full-term neonates [7]. ...
Transient tachypnoea of the neonate (TTN) is the commonest neonatal respiratory disorder, but it is quite mild and so has been the subject of relatively little academic and educational work. Recent animal studies and the introduction of new bedside monitoring techniques ( e.g. quantitative lung ultrasound and electrical cardiometry) have clarified its pathogenesis. Given its high incidence, TTN is a relevant public health issue and its clinical management should be considered in an era of resource constraints. This review focuses on the latest data on TTN in terms of its pathophysiology, biology, diagnosis, imaging, therapy and cost-effectiveness, so as to optimise clinical care at the bedside. The need for a new pathophysiology-based definition of TTN is also highlighted and the available therapeutics are analysed considering the associated public health issues. This updated knowledge can help to improve the management of TTN and impact positively on its relevant public health consequences. This is particularly important since the mortality of TTN is virtually nil and so cannot be used to evaluate any clinical innovation. We also aim to give some practical guidance for the real-world clinical management of TTN and contribute to the training of neonatologists who care for TTN patients.
... 7,8 However, patients delivered via cesarean section (C/S) without labor are known to be at increased risk for respiratory distress. [9][10][11][12][13] Respiratory status factors heavily into a patient's clinical assessment and can trigger an evaluation for EOS and initiation of empiric antibiotics when using any of the three currently recommended approaches to EOS risk assessment: categorical risk assessment, multivariate risk assessment (the Neonatal Early-Onset Sepsis Calculator), and enhanced observation. 14 Contemporary efforts to more accurately identify infants at risk for EOS revolve primarily around the utilization of multivariate risk assessment via the Neonatal Early-Onset Sepsis Calculator. ...
... 14 Infants born via C/S without labor are known to be at higher risk for noninfectious respiratory morbidity. [9][10][11][12][13] As in our cohort, these patients often require respiratory support outside of the delivery room, a marker of clinical illness and an indication for empiric antibiotic treatment using any of the three currently recommended EOS assessment tools. Within our cohort, 14.6% of neonates had a diagnosis of respiratory distress and 13.7% required respiratory support outside of the delivery room. ...
Objective:
To compare early-onset sepsis (EOS) risk estimation and recommendations for infectious evaluation and/or empiric antibiotics using a categorical risk assessment versus the Neonatal Early-Onset Sepsis Calculator in a low-risk population.
Study design:
Retrospective chart review of late preterm (≥35 + 0/7 - 36 + 6/7 weeks' gestational age) and term infants born at Brooke Army Medical Center between January 1, 2012-August 29, 2019. We evaluated those born via cesarean section (C/S) with rupture of membranes (ROM) < 10 minutes. Statistical analysis was performed to compare recommendations from a categorical risk assessment versus the calculator.
Results:
We identified 1,187 infants who met inclusion criteria. A blood culture was obtained within 72 hours after birth from 234 (19.7%) infants and 170 (14.3%) received antibiotics per routine clinical practice, using categorical risk assessment. Respiratory distress was the most common indication for evaluation, occurring in 173 (14.6%) of patients. After applying the Neonatal Early-Onset Sepsis Calculator to this population, the recommendation was to obtain a blood culture on 166 (14%), to start or strongly consider starting empiric antibiotics on 164 (13.8%), and no culture or antibiotics on 1,021 (86%). Utilizing calculator recommendations would have led to a reduction in frequency of blood culture (19.7% vs 14%, p-value <0.0001) but no reduction in empiric antibiotics (14.3% vs. 13.8%, p-value 0.53). There were no cases of culture proven EOS.
Conclusion:
This population is low-risk for development of EOS; however, 19.7% received an evaluation for infection and 14.3% received antibiotics. Utilization of the Neonatal Early-Onset Sepsis Risk Calculator would have led to a significant reduction in the evaluation for EOS but no reduction in antibiotic exposure. Consideration of delivery mode and indication for delivery may be beneficial to include in risk assessments for EOS.
... Infants born by elective cesarean section (ECS) are at higher risk of developing respiratory dysfunction than those born vaginally at the same gestational age. In most cases, the symptoms are mild and temporary, but some infants develop severe respiratory illness [4][5][6]. This article provides an overview of fetal lung development, the etiology and pathophysiology of lung diseases associated with ECS, and current recommendations for their management. ...
... Infants born by ECS are at more risk for respiratory dysfunction shortly after birth than those born vaginally, and the incidence is inversely related to gestational age [1,[4][5][6]31]. To decrease the risk, it is recommended that ECS should not be performed before 39 weeks of gestation, unless medically indicated [29,[31][32][33]. ...
Purpose of Review
Infants born by elective cesarean section (ECS) are at increased risk for respiratory dysfunction due to inadequate lung fluid clearance, surfactant deficiency, and increased pulmonary vascular resistance. The purpose of this article is to give insight into the etiology and pathophysiology of lung diseases in neonates born by ECS, as well as current recommendations for their management.
Recent Findings
The diagnosis and management of respiratory disorders in neonates has improved in recent years with better diagnostic methods and treatment options. Antenatal corticosteroids (ACS) have been shown to decrease respiratory morbidity associated with ECS in near-term and term infants, but a recent systematic review of 30 studies showed a significantly higher risk for adverse neurocognitive and psychological outcomes in children with ACS exposure during late-preterm and full-term birth than non-exposed children.
Summary
This review focuses mainly on current treatment options for respiratory diseases in neonates born by ECS, and a brief review of pulmonary fetal development and postnatal adaption is also included. ACSs have been used to reduce respiratory morbidity associated with ECS but are associated with increased risk of adverse neurocognitive and psychological outcomes in children born term or near-term.
... A child born by cesarean section at term is therefore more likely to have a lung resorption disorder than a child born by vaginal delivery. J. Morrison showed in a study that the rate of respiratory distress after cesarean section was significantly higher than after vaginal delivery [10]. Studies show that the rate of admission to intensive care units is greater for children born at term by cesarean section before labor than for children who have gone into labor. ...
... The interest of preventive corticosteroid therapy is to reduce the rate of transient respiratory distress and hospitalizations in intensive care unit and resuscitation. [8,9,10] ...
Introduction: The practice of planned elective cesarean sections (ECS) in the near-term pregnant woman is often perceived as an act ensuring maximum safety for the mother and her child. However, in terms of morbidity and maternal-fetal mortality, Cesarean section is worse than a vaginal delivery. Materials and methods: Our work is a prospective, comparative study of planned elective cesarean sections performed in our institution. Results: The prevalence of neonatal hospital admissions was 24.6% in the case of a planned elective cesarean section and 17.8% in the case of an emergency caesarean section, compared to 19.9% in the case of vaginal delivery. The transfer to neonatology department for respiratory distress syndrome (RDS) concerns 21.8% of births per planned cesarean section, 12.3% of emergency cesarean births, and 11.5% of vaginal delivery. Conclusion: The rate of respiratory distress syndrome due to alveolar fluid resorption disorder is greater when the child is born by elective cesarean section than when he was born by emergent cesarean section or through vaginal delivery. While the rate of perinatal asphyxia is reduced in the event of an elective cesarean section.
... The benefit falls with increasing gestation, supporting the recommendation to delay elective caesarean section until the 39th week. Nevertheless, the benefits of antenatal steroids persist till 39 weeks (6) . ...
... Preterm birth is the most costly complication of pregnancy and the leading cause of neonatal morbidity and mortality. There are multiple strategies to minimize the risk and the impact of prematurity, such as administration of antenatal corticosteroids (8) .When infants were delivered near or at term especially by elective caesarean delivery before the onset of spontaneous vaginal delivery, usually they are deprived of necessary hormonal changes resulting in the development respiratory complications especially neonatal respiratory distress syndrome (6) . Caesarean section carried out before the onset of labor is considered to increase the risk of RDS the incidence of respiratory distress syndrome was approximately 0.37 % among those neonates delivered by elective caesarean section (5) .Antenatal corticosteroid therapy were thought to improve surfactant production and there was also an associated reduction in the risk of neonatal intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity, neonatal death and infant mortality by (30%), neonatal respiratory distress syndrome by(50%), and of both intracranial hemorrhage and periventricular leukomalacia by(70%) the later 2 conditions are among the best predictors of long term neurodevelopment injury, including cerebral palsy (9) . ...
... In the discussion about the best mode of delivery, the long-term consequences for infants unnecessarily delivered by planned cesarean section are insufficiently acknowledged. Compared to vaginal delivery, primary cesarean section is significantly more frequently associated with respiratory distress owing to delayed alveolar fluid clearance [16], bronchial asthma [17], overweight and obesity [18], inflammatory bowel disease [19] and diabetes mellitus type I [20] in later childhood. Also increased are maternal morbidities, especially with regard to possible subsequent pregnancies, after a cesarean section: placenta previa, placenta accrete, placental abruption [17], blood loss and wound pain [4]. ...
... This is a very important finding: women who meet the framework conditions for vaginal breech delivery have no disadvantage with regard to the neonatal outcome if the vaginal delivery is aborted and a secondary cesarean section is performed. Rather, the children with secondary cesarean section seem to benefit from the "positive stress of labor" [16]. Even if the ventilation times after a planned primary cesarean section did not differ significantly from these after vaginal breech delivery and secondary cesarean due to the small number of cases, the results show a tendency. ...
Objectives
The safest mode of delivery for fetuses in breech presentations is still an ongoing debate. The aim of this study was to analyze neonatal admission rates after vaginal breech delivery and compare it to other modes of delivery in order to counsel pregnant women with breech presentation adequately.
Methods
We performed a retrospective monocentric analysis of all deliveries with singleton pregnancies in breech presentation > 36.0 weeks of gestation between 01/2018–12/2019. Short-term neonatal morbidity data was collected for vaginal delivery and primary as well as secondary cesarean sections from breech presentations.
Results
A total of n=41/482 (8.5%) neonates had to be admitted to NICU: vaginal breech delivery n=18/153 (11.8%), primary cesarean section n=9/101 (8.9%, OR 0.73; CI 0.32–1.70; p=0.47), secondary cesarean section n=10/76 (13.2%, OR 1.14; CI 0.50–2.60, p=0.76) and vaginal vertex delivery n=4/152 (2.6%, OR 0.20; CI 0.06–0.51; p=0.005). There was no significant difference in transfer to NICU between all breech position delivery modes. Despite significantly lower pH and 5’ APGAR values after vaginal delivery, neonates delivered by primary cesarean section and NICU admission had to be treated there significantly longer (mean 80.9 vs. 174.0 h). No significant difference in terms of ventilation parameters and infections were found between the vaginal delivery, primary and secondary cesarean section from breech presentation.
Conclusions
Vaginal breech delivery does not result in a higher neonatal admission rate in comparison to primary and secondary section. In contrast, there is a shorter NICU duration in case of neonatal admission after vaginal delivery.
... Today, 3 out of 4 preterm babies are born near term (4). Previous studies have shown significantly higher incidence of respiratory morbidity in the group of newborns delivered before 39 weeks of gestation (16,20). TTN is a common cause of RD in early neonatal period, especially in the group of neonates born near term (18,20). ...
... One study did not show a decreased risk of TTN development in preterm neonates born after CS with previous signs of spontaneous delivery (6). Nevertheless, researchers described that respiratory symptoms were significantly more frequent after planned Cesarean delivery (16). Fetal increase of catecholamine concentrations provoked by spontaneous labor and rupture of fetal membranes, are additional factors which regulate the absorption of lung fluid and stimulate surfactant release (2). ...
Transient tachynpea of the newborn, which is a self-limiting condition, in some cases requires invasive respiratory support. This study aimed to investigate the influence of gestational age and mode of delivery on oxygen therapy, and the occurence of complications. This retrospective study covered data about children diagnosed with transient tachypnea who were born during the period of one year. The duration of oxygen therapy and the assessment of complications were analyzed according to the mode of delivery and gestational age. In 77,3% of cases transient tachypnea was well-managed with the use of oxygen therapy in incubator. In relation to the mode of delivery and gestational age, no significant differences in the duration of different oxygen therapy types were observed. Two newborns developed persistent pulmonary hypertension, and one newborn had pneumothorax. Invasive respiratory support is not frequently used in transient tachypnea. Persistent pulmonary hypertension and air leak syndrome are possible but very rare complications of this condition.
... The incidence of TTN is greatest in babies born at term by cesarean section (CS) without labor and is increasing in parallel with the growing rates of elective CS worldwide (3,6,7). Historically, treatment of TTN has largely focused on targeting molecular airway liquid clearance mechanisms, which includes the pharmacological stimulation of sodium reabsorption with beta-receptor agonists and restricting newborn fluid intake ( Figure 1). ...
... The physiological benefits of being exposed to labor and uterine contractions (i.e., CS with labor vs. elective CS) can reduce the risk of respiratory distress after a CS delivery, but still carries a greater risk compared to vaginal birth (6). As delivery by elective CS is the greatest risk factor for TTN, avoiding planned CS without medical indication would appear logical and is consistent with the World Health Organization recommendations (24). ...
Respiratory distress in the first few hours of life is a growing disease burden in otherwise healthy babies born at term (>37 weeks gestation). Babies born by cesarean section without labor (i.e., elective cesarean section) are at greater risk of developing respiratory distress due to elevated airway liquid volumes at birth. These babies are commonly diagnosed with transient tachypnea of the newborn (TTN) and historically treatments have mostly focused on enhancing airway liquid clearance pharmacologically or restricting fluid intake with limited success. Alternatively, a number of clinical studies have investigated the potential benefits of respiratory support in newborns with or at risk of TTN, but there is considerable heterogeneity in study designs and outcome measures. A literature search identified eight clinical studies investigating use of respiratory support on outcomes related to TTN in babies born at term. Study demographics including gestational age, mode of birth, antenatal corticosteroid exposure, TTN diagnosis, timing of intervention (prophylactic/interventional), respiratory support (type/interface/device/pressure), and study outcomes were compared. This narrative review provides an overview of factors within and between studies assessing respiratory support for preventing and/or treating TTN. In addition, we discuss the physiological understanding of how respiratory support aids lung function in newborns with elevated airway liquid volumes at birth. However, many questions remain regarding the timing of onset, pressure delivered, device/interface used and duration, and weaning of support. Future studies are required to address these gaps in knowledge to provide evidenced based recommendations for management of newborns with or at risk of TTN.
... This nding contrasts with some literature, which suggests that cesarean section may increase the risk of respiratory complications in neonates, thus leading to higher NICU admissions (7,8). The increased NICU admission rates in cesarean deliveries may be attributed to factors such as the absence of labor, which deprives neonates of the physiological hormonal benets that facilitate lung maturation and uid clearance during vaginal delivery (9). ...
Premature rupture of membranes (PROM) refers to the spontaneous rupture of the amniotic sac before the onset of labor, which occurs in about 3-10% of pregnancies. It can lead to complications such as infection, placental abruption, and fetal distress if not managed appropriately. When PROM occurs preterm (before 37 weeks), it is referred to as preterm premature rupture of membranes (PPROM). In cases of PROM, labor is typically induced to reduce the risk of infection, especially after 34 weeks of gestation (1). The method of delivery, whether normal vaginal delivery or lower segment cesarean section (LSCS), remains a crucial decision point, as it inuences maternal and fetal outcomes (2).
... The onset of labor contractions has a positive influence on reducing the occurrence of neonatal respiratory adaptation disorders (19). As shown by Morrison et al., neonatal morbidity was significantly increased when Csections were carried out before the start of labor (planned C-sections) compared to vaginal births and C-sections after the start of contractions and/or the rupture of the membranes (emergency C-sections) (20). As a result, aiming for and experiencing contractions and the rupture of the membranes is the focus of modern obstetrics, regardless of the success of an attempted vaginal birth. ...
Background/aim:
Our study compares repeat cesarian section with and without labor in progress and evaluates adverse maternal outcomes that could discourage pregnant women in planning labor at term or at least after 39 weeks of gestation as recommended due to benefits in neonatal outcome.
Patients and methods:
In this retrospective study, we analyzed 191 patients undergoing third C-section and compared two groups of women of undergoing C-section either before or after the onset of labor. The primary outcome measure was the incidence of maternal morbidity. Values of p≤0.05 were regarded as significant.
Results:
Comparing the two subgroups, we did not find any significant differences in the occurrence of maternal complications or severe acute morbidity except for incomplete uterine rupture (p=0.04).
Conclusion:
Undergoing a third C-section after the start of labor has no relevant or adverse impact on maternal outcome. Therefore, elective repeat C-section can be planned in late weeks of gestation aiming at reducing neonatal morbidity. The higher rate of uterine dehiscence was not associated with other issues of severe acute maternal morbidity.
... Known risk-factors for adverse neonatal outcome in late preterm infants are lower gestational age [23][24][25], low birthweight [24,[26][27][28], male fetus [27,29], gestational diabetes and large-for-gestational-age [24,30,31], chorioamnionitis [31], medically indicated delivery [32] and cesarean section [24,[33][34][35]. As reported in Section "Pregnancy Characteristics and Risk Profiles" we did not find any significant group differences, concerning these possible Content courtesy of Springer Nature, terms of use apply. ...
Purpose
Many pregnancies continue after antenatal corticosteroid exposure. Since long-term effects on late preterm neonatal outcome remain controversial, it remains unknown whether pregnant women who are at risk for preterm birth during the late preterm period and had prior antenatal corticosteroid exposure would benefit from an additional course of antenatal corticosteroids. We evaluated the need for future trials on this topic by comparing short term effects from antenatal betamethasone to long-term effects. We also examined the value of a risk-adapted approach.
Methods
We observed neonatal outcomes in late preterm infants (34/0–36/0 weeks of gestation) who were exposed to antenatal betamethasone either up to 10 days prior birth (n = 8) or earlier in pregnancy (n = 89). We examined a real world population from the University Hospital Magdeburg (Germany) between 01 January 2012 and 31 December 2018, and a simulated high-risk population that was derived from the original data.
Results
The indicators for relevant adverse outcomes did not differ in the unselected population. In the simulated high-risk population, recent antenatal corticosteroid administration significantly reduced the incidence of relevant cardiorespiratory morbidities (OR = 0.00, p = 0.008), and reduced the number needed to treat from 3.7 to 1.5.
Conclusion
The superiority of recent antenatal corticosteroid administration in the late preterm period over earlier exposure strongly depended on the prevalence of respiratory disease. Before considering clinical trials on additional antenatal corticosteroid courses in the late preterm period, antenatal assessment tools to predict respiratory morbidity need to be developed.
... Studies have consistently shown a higher risk of neonatal respiratory morbidity in infants born by elective C-section, especially at 37 and 38 weeks' gestation [8]. However, performing elective C-section in the week 39 + 0 to 39 + 6 of pregnancy has been linked to a significant reduction in neonatal respiratory morbidity [26,27]. While elective C-section reduces the occurrence of birth asphyxia and trauma, it increases the risk of respiratory distress secondary to TTN, surfactant deficiency, and pulmonary hypertension [20]. ...
Cesarean section (C-section) delivery is associated with a higher risk of respiratory problems in newborns, particularly if performed electively at 37 weeks. This risk is greater than with spontaneous or induced labor but diminishes as gestation advances. To lower the incidence of respiratory issues in newborns, it is vital to promote natural labor, avoid unnecessary C-sections, and offer thorough prenatal care. Healthcare providers and expectant mothers should assess the risks and benefits of elective C-sections carefully. By advocating for natural labor and reducing unnecessary C-sections, the occurrence of respiratory problems in newborns can be decreased. Adequate prenatal care and monitoring are crucial for identifying and managing potential risk factors for respiratory diseases in newborns. It is crucial for healthcare professionals to educate expectant mothers about the risks of elective C-sections and the advantages of allowing labor to progress naturally. By fostering transparent communication and collaborative decision-making between healthcare providers and pregnant women, well-informed choices can be made that prioritize the health of both the mother and the baby. Furthermore, ongoing research and advancements in medical technology can improve our understanding of how delivery methods affect newborn respiratory health, ultimately leading to better outcomes and care practices in the future.
... This recommendation is based on a subset of several observational studies suggesting a strong association between earlier gestational age at elective caesarean section delivery and risk of respiratory morbidity. [3][4][5][6][7] In addition, two recent, large cohort studies investigated timing of elective caesarean section and the incidence of a composite adverse neonatal outcome including neonatal death or any of a series of adverse events. Both showed a decreasing incidence of the composite outcome with increasing gestational age from 37 to 39 completed weeks of gestation. ...
... Caesarean delivery rates are increasing worldwide and are sometimes associated with adverse maternal and neonatal outcomes [1][2][3][4]. ...
Repeat caesarean sections increase the possibility of maternal morbidity. Worldwide, the need for a trial of labor after caesarean delivery is gaining more ground in selected cases. Here, we report a case of an unbooked 37-year-old multigravida, with a history of five (5) previous lower-segment caesarean sections who presented in spontaneous labor. A live male baby of 2900 grams was delivered following episiotomy. Post-partum, she was observed with normal findings and a serial follow-up ultrasound scan showed normal uterine contours and surrounding structures. As the evidence for the practice of vaginal delivery in women who underwent 2 or more previous LSCS are still fewer, this report intends to highlight the possibility of successful vaginal birth after multiple caesarean sections putting into consideration the optimal care of the parturient. The term ''V-back" was coined from the Roman numeral 'v' meaning five (5), the case here has had five (5) previous lower segment cesarean sections come "back" for spontaneous vaginal delivery.
... (n=6) developed moderate to severe and prolonged RDS as compared to babies born with AFOD value < 0.40 after 39 wks gestational age who developed milder RDS for shorter duration. The findings are in accordance with the previous studies (27)(28).AFOD represents indirectly the amount of surfactant. Hence severity depends on the how low the AFOD value is or in other words how low the surfactant phospholipids are and not always how low the chronological age is. ...
Objective: To establish the correlation between the
Amniotic fluid (AF) Optical density (OD) at the
onset of spontaneous labor and the functional
maturity, gestational age and birth weight of the
newborn.
Methods: Uncentrifuged fresh amniotic fluid
samples from 360 singleton pregnancies were
collected during artificial rupture of membranes or
amniotomy at LSCS after onset of labor for AFOD
estimation at 650 nm .
Results: The mean AFOD at spontaneous labor
was found to be 0.98±0.27 (n=360). The study
population was divided into 7 different groups
according to gestational age (GA) (35 1/7 -36 wks,
36 1/7-37wks, 37 1/7-38 wks, 38 1/7-39 wks, 39
1/7-40 wks , 401/7-41wks, and above 41 wks of
GA respectively). In different GA groups, the mean
AFOD at spontaneous labor ranged from
0.50±0.13 to 1.03±0.24. Between any two groups
among 2 to 7 (i.e. after 36 wks GA) when cases of
respiratory distress syndrome (RDS) was
excluded, there is no essential change in mean
AFOD values (range 0.85 to 1.03). The results
were same after adjusting for birth weights. All the
babies delivered at AFOD value of mean ± SD
0.98 ±0.27 (0.40 to 1.55 CI 95 %) ,were fully
functionally mature and did not develop RDS.
Babies born with AFOD < 0.40 (n=8) had varying
degrees of RDS with birth weights ranging from
2300 to 3000 gms. Also they had more vernix on
their body than the non RDS babies The mean
birth weights progressively increased from group 1
to 7.
Synopsis: Spontaneous normal labor takes
place with complete fetal functional maturity at an
optimum AFOD value of 0.90 irrespective of the
GA and birth weight in our study population. The
correlation of AFOD with functional maturity
supports the concept of individual term
... They could only be avoided by a delivery policy at 32 weeks gestation. This would be unacceptable due to neonatal morbidity (21) . ...
Background Abnormal invasive placentation leads to massive intraoperative bleeding and maternal morbidity or death. The current study aimed to evaluate the role of systemic pelvic devascularization technique in reducing cesarean hysterectomy in pregnancies involved in PAS and its complication. Objectives To deterime role of early claming of uterine artery and delayed placental separation in reducing the consequences of placenta accreta spectrum disorders Patients and Methods Case series research was done in a Maternity Teaching Hospital as a single center study on twenty high-risk pregnant ladies at (32 to37 weeks) gestation diagnosed with placenta accrete through ultrasonography from the first of January 2021 to the first of November 2021. All patients were managed through the technique of delayed delivery of the placenta and early clamping uterine artery at the level of the internal os of the cervix using two vascular clamps followed by immediate ligation of the anterior branch of the internal iliac artery (IIA) in the retroperitoneal space within 1-2 minutes which shows a significant reduction in blood loss at placental bed following placental delivery, neither of cases ended by cesarean hysterectomy, written consent has been taken from the enrolled patients. A college has approved the study of the medicine Ethical Committee /the University of Sulaimani. Data from the current study has been analyzed using “IBM SPSS statistics version 25”. Results Among the patients who participated in the present study, the mean±SD of age was 37.1 ± 4.5 years range (30-48) years old, and the mean±SD gestational age was 36 ± 1.5 range (32 to 38) weeks, their mean ±SD of BMI (body mass index) was 28 ± 2.2 (range, 24 to 32). The mean±SD cesarean count was 2.8 ± 1.3 (range, 0-5). The mean±SD of patients’ gravida and parity were 4.2 ± 1.6 (range,1-7) and 2.8 ± 1.4 (range,0-5), respectively.The mean±SD operation time varies 93 ± 25.6 range (60 to 120 minutes ); neither of the cases ended by hysterectomy, hemoglobin levels were also taken as part of the investigation, and its level preoperatively means ± SD 11.4 ± 1.1( range, 9.9 to 13.9) and post-operatively mean ± SD level was 9.6 ± 1.2 (range, 7.2 to 11.1), significantly less blood loss seen intraoperatively and only 75% of them require blood transfusion and only one-day hospital stay after the operation, no one requires the second laparotomy. Therefore, there was no significant association between them; thence, the mentioned procedure is clinically beneficial. Conclusion This method did not need to cesarean hysterectomy, so it causes less blood loss and morbidity.
... 22 Regardless of gestational age, babies born via elective CS do not have the usual physical and hormonal stimuli of passage through the birth canal; thus, they tend to have higher rates of respiratory morbidity. [23][24][25] Some studies have suggested that the risk of neonatal hypoglycaemia is greater following CS; however, this may be confounded by the underlying indication for CS. 26 In 2016, members of our team published a systematic review assessing the effectiveness of ACS therapy in these four clinical situations. 27 No direct evidence of the effects of ACS therapy on pregnant women with diabetes who were at risk of preterm birth or for those undergoing elective CS in the late preterm period was found. ...
Objective
This study aimed to synthesise available evidence on the efficacy of antenatal corticosteroid (ACS) therapy among women at risk of imminent preterm birth with pregestational/gestational diabetes, chorioamnionitis or fetal growth restriction (FGR), or planned caesarean section (CS) in the late preterm period.
Methods
A systematic search of MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science and Global Index Medicus was conducted for all comparative randomised or non-randomised interventional studies in the four subpopulations on 6 June 2021. Risk of Bias Assessment tool for Non-randomised Studies and the Cochrane Risk of Bias tool were used to assess the risk of bias. Grading of Recommendations Assessment, Development and Evaluations tool assessed the certainty of evidence.
Results
Thirty-two studies involving 5018 pregnant women and 10 819 neonates were included. Data on women with diabetes were limited, and evidence on women undergoing planned CS was inconclusive. ACS use was associated with possibly reduced odds of neonatal death (pooled OR: 0.51; 95% CI: 0.31 to 0.85, low certainty), intraventricular haemorrhage (pooled OR: 0.41; 95% CI: 0.23 to 0.72, low certainty) and respiratory distress syndrome (pooled OR: 0.59; 95% CI: 0.45 to 0.77, low certainty) in women with chorioamnionitis. Among women with FGR, the rates of surfactant use (pooled OR: 0.38; 95% CI: 0.23 to 0.62, moderate certainty), mechanical ventilation (pooled OR: 0.42; 95% CI: 0.26 to 0.66, moderate certainty) and oxygen therapy (pooled OR: 0.48; 95% CI: 0.30 to 0.77, moderate certainty) were probably reduced; however, the rate of hypoglycaemia probably increased (pooled OR: 2.06; 95% CI: 1.27 to 3.32, moderate certainty).
Conclusions
There is a paucity of evidence on ACS for women who have diabetes. ACS therapy may have benefits in women with chorioamnionitis and is probably beneficial in FGR. There is limited direct trial evidence on ACS efficacy in women undergoing planned CS in the late preterm period, though the totality of evidence suggests it is probably beneficial.
PROSPERO registration number
CRD42021267816.
... Several studies have indicated that elective cesarean section and male sex are risk factors for respiratory distress 22-25 . Although no association was found between cesarean section and newborn morbidity, the percentage of cesarean sections in both ETNBs (47.7%) and FTNBs (42.7%) was higher than the WHO recommendation of 10%-15% 26 , a situation that has been occurring in high, medium, and low income countries 27 . As cesarean section impairs the prognosis of ETNBs 28,29 , some countries have implemented strategies to reduce deliveries before 39 weeks 30 with good results; for example, not performing any indicated deliveries (both induction of labor and cesarean) before 39 weeks in uncomplicated pregnancies. ...
Background:
The morbidity of early-term newborns (ETNBs) is associated with the immaturity of their organs and maternal biological factors (MBF). In this study, we determined the relationship between MBF and early-term birth. In addition, we assessed the role of gestational age (GA) and MBF in the morbidity of ETNBs compared with full-term newborns (FTNBs).
Methods:
This retrospective cohort included ETNBs and FTNBs. The frequency of morbidities was compared between groups stratified by GA with the X2 test or Fisher's exact test. The association of MBF with GA and morbidity was calculated using binomial regression models between the variables that correlated with the morbidity of the ETNBs using Spearman's correlation. A significance level of 5% was estimated for all analyses.
Results:
The probability of morbidity at birth for ETNBs was 1.9-fold higher than for FTNBs (37.5% vs. 19.9%), as they required more admission to the neonatal unit and more days of hospitalization; the most frequent pathology was jaundice. The MBF associated with early term birth were hypertensive disorders of pregnancy (aRR = 1.4, 95% confidence interval (CI): 1.3-1.6), intrauterine growth restriction (aRR = 1.5, 95% CI: 1.3-1.6), and chronic hypertension (aRR = 1.6, 95% CI: 1.4-1.8). No association was found between MBF and morbidity at 37 and 38 weeks.
Conclusions:
The morbidity among ETNBs is related to physiological immaturity. The adverse MBF favor a hostile intrauterine environment, which affects fetal and neonatal well-being.
... This lower rate could be based on the early detection and timely decision making as all the CS in the hospital are done by experienced obstetrician only. The lower rate of respiratory problems in elective CSs might be because of term delivery as mean gestational age of elective CS is 38 weeks as shown by some authors 22 . ...
Introduction: Caesarean delivery is the most commonly performed lifesaving procedure in obstetrics. Caesarean section can be done in emergency and elective basis. There has been rising trend of caesarean section over the last few decades. Both the caesarean sections are associated with fetal risks than vaginal delivery. Objectives: To assess and compare the perinatal outcomes of emergency and elective caesarean sections. Methods: It was a cross-sectional comparative study done in Civil Service Hospital of Nepal over the period of one year starting from January 2021 to December 2021. All the patients who underwent caesarean section during the study period were taken into study. Data regarding perinatal outcomes were analysed by SPSS software. Results: During the study period, there were 1349 total deliveries. Caesarean sections accounted for 52.2% (n=705) of all deliveries. There were a total of 373 (52.9%) emergency CS and 332 (47.1%) elective CS. Most common indications of emergency and elective caesarean section were fetal distress and previous caesarean section respectively.Out of 713 new-born’s, 26 (6.9%) were preterm in emergency CS, 4 (2.1%) in elective group which was statistically significant (X2 <0.001). Regarding APGAR score, need of resuscitation, nursery admission, respiratory distress syndrome, and neonatal intensive care unit transfer, neonates delivered by emergency basis had more number of babies than elective. However, there was no significant difference. There was one early neonatal death in the study period. Conclusion: Caesarean section is in rising trend of late. However, timely decision making skills can certainly lead to better perinatal outcome in caesarean sections.
... The infants born by cesarean section are more likely to develop respiratory morbidity. In contrast, infants born vaginally are more likely to develop intracranial hemorrhage, brachial plexus injury, and culture-positive neonatal sepsis (10)(11) . Life-threatening maternal outcomes are more common in cesarean deliveries regardless of previous vaginal delivery history. ...
Objective:
The aim of this study was to evaluate the short-term results of perinatal health in vaginal and cesarean deliveries and the indications for admission to the neonatal intensive care unit (NICU) in terms of healthy singleton pregnancies.
Materials and methods:
In this study, 300 pregnant women who gave birth in our tertiary hospital was included. The records of newborns admitted to the NICU of these pregnant women were reviewed between January 1, 2019 and January 1, 2021. Durations of newborn hospitalizations and problems encountered during admission were recorded. The results were statistically evaluated.
Results:
There was no significant difference between vaginal delivery and cesarean section groups in terms of the indications for admission to the NICU of term low-risk pregnant women (p=0.91, p=0.17). A higher admission in the NICU was found in the early term group. The early term group required more respiratory support compared to the full term group (p=0.02). When the groups were compared in terms of IV fluid treatment support, hypoglycemia or feeding difficulty, and jaundice requiring phototherapy, no significant difference was found.
Conclusion:
Withlimited data available for admission indications to the NICU of newborns born from term pregnancies, we found that the mode of delivery affects hospitalization indications of newborns, need for support, and Apgar scores. Early term delivery is associated with higher rates of neonatal morbidity and admission to the NICU. Better maternal care and prevention of factors that may lead to preterm birth will provide the prevention and management of these problems.
... The American College of Obstetricians and Gynecologists in 2013 recommended that vaginal delivery in the absence of fetal and maternal indications is much safer for the fetus. The risk of respiratory morbidity, including transient tachypnea of the newborn, respiratory distress syndrome, and persistent pulmonary hypertension, is higher for elective cesarean delivery compared with vaginal delivery when delivery is earlier than 39-40 weeks of gestation (21,22) . ...
... The current recommendations for the timing of delivery of women with uncomplicated placenta previa are between 36 0/7 and 37 6/7 weeks of gestation [9,10], but the evidence regarding this recommendation is limited, and based largely on expert consensus and relevant observational studies. Previous studies have showed that neonatal morbidity, even in an elective term CD, diminishes significantly after 38 6/7 weeks [5,16,17]. A previous study by Zlatnik, who attempted to establish a decision analytic model comparing maternal and neonatal outcome, concluded that the optimal time of delivery for women with a placenta previa is at 36 weeks following steroid administration. ...
Objective
The optimal timing of an elective cesarean delivery for uncomplicated placenta previa remains controversial. Although the present guidelines recommend an elective cesarean delivery between 360/7 and 376/7 weeks of gestation, data supporting this recommendation does not differentiate in outcomes between elective and emergent delivery, or between women with and without ante-partum hemorrhage. Recommendations regarding optimal timing of delivery are based on the risks and benefits associated with delivery at a certain gestational week, compared with a reference of 38 weeks. Therefore, the aim of this paper was to assess the maternal and neonatal adverse outcomes associated with elective delivery at different gestational weeks from 360/7 to 386/7 weeks compared with expectant management in women with uncomplicated placenta previa.
Methods
A retrospective cohort study in a single tertiary medical center of 251 women with a diagnosis of uncomplicated placenta previa, who delivered between 360/7 and 386/7 weeks of gestation, who delivered at our center between Jan 2011 and Dec 2019. Maternal and neonatal outcomes at each gestational week were compared with expectant management.
Results
At 360/7–366/7 weeks, the rate of composite maternal adverse outcome was similar for elective delivery and expectant management (10.5% vs 7.7%, p = .68). Similarly, at 370/7–376/7 the rate of composite maternal adverse outcome was comparable for elective cesarean delivery and expectant management (7.2% vs 6.4%, p = .54). Maternal bleeding was the main indication of an urgent cesarean delivery, and account for 86% of urgent cesarean delivery at 360/7–366/7, 76.4% of urgent cesarean delivery at 370/7–376/7, and for 70.6% of all urgent cesarean delivery at 380/7–386/7 weeks. This group of women who were delivered due to maternal bleeding had a history of maternal bleeding during 2nd and/or 3rd trimester in 75–92.3% of cases. Composite adverse neonatal outcome was similar for elective cesarean delivery at each gestational age compared with expectant management. The risk for lower 5-min APGAR score and hypoglycemia was higher for newborns that were delivered electively a 36th weeks of gestation compared with expectant management.
Conclusion
Our study suggests that the optimal time of delivery for women with an uncomplicated placenta previa is between 380/7 and 386/7 weeks of gestation, especially in women without ante-partum bleeding.
... Therefore, many guidelines recommend that planned caesarean section should not be routinely carried out before 39 weeks of gestation. 21,22 Our study was designed to compare neonatal respiratory morbidity in patients delivered between 37 to 38 +6 by planned caesarean section with or without injection of dexamethasone given intramuscularly to mothers 48 to 72 hours before delivery. Results of this study showed that neonatal respiratory morbidity was significantly higher in women who were not given dexamethasone i.e. ...
Performing elective caesarean section prior to 39 completed weeks, it can lead to breathing problems in neonates as compare to those, who are born through caesarean section without antenatal Corticosteroid. WHO recommends the administration of intramuscular corticosteroids either dexamethasone or betamethason (total 24mg in divided doses) in the antenatal period, when there is a risk of preterm birth. The advantages and disadvantages of a similar regimen given after 37 weeks of pregnancy prior to elective caesarean section (LSCS) to prevent respiratory morbidity in a newborn is yet a topic of discussion.
In Pakistan still, many clinicians are doing caesarean section at 37 or 38 weeks without antenatal Corticosteroids. The rationale is to emphasize the use of steroids before caesarean at 39 weeks.
... TTN, which occurs in about five or six per 1,000 births [15] Newborns with TTN have a greater risk of developing asthma in childhood; in one study, this association was stronger in patients of lower socioeconomic status, nonwhite race, and males whose mothers did not have asthma [16] . TTN results from delayed reabsorption and clearance of alveolar fluid. ...
... Delayed resorption of fetal lung fluid is thought to be the underlying cause of transient tachypnea of the newborn (TTN) [1]. Birth by cesarean section (C/S), maternal diabetes and asthma, birth without labor, lower gestational age, macrosomia, male sex, and perinatal asphyxia are common risk factors for TTN [2][3][4]. TTN is a benign disorder in which clinical symptoms generally regress spontaneously within 48-72 hours. ...
Background:
Transient tachypnea of the newborn (TTN) is a common clinical problem that often occurs in the first hours of life. Although it is considered to be a benign clinical course, some cases may have severe symptoms and require ventilation support. In this study, we aimed to determine the association between the mean platelet volume (MPV), nucleated red blood cells (NRBCs), right ventricular systolic pressure (RVSP), and the severity of TTN.
Methods:
Patients with TTN were divided into two groups according to Silverman score (<7: group 1 [n: 34] and ≥7: Group 2 [n: 30]). The groups were compared in terms of demographic characteristics, hematologic parameters, and RVSP within the first 24 hours after admission.
Results:
Mean birth weight of the patients was 3033.4 ± 364.1 g and median gestational age was 38 weeks (min-max: 34-42). Patients in Group 2 were found to require higher nasal continuous positive airway pressure (nCPAP) support and longer duration of oxygen treatment (p: 0.001). Patients in Group 2 had significantly higher thrombocyte, absolute NRBCs count, NRBCs/100 WBCs, and RVSP levels (p < 0.05). Hemoglobin and hematocrit levels were found significantly higher in group 1(p < 0.05). In logistic regression analysis, NRBCs/100 WBCs was found to be the most important independent parameter that affects Silverman score at admission (OR: 7.065, CI: 1.258-39.670, p: 0.026).
Discussion:
This is the first study that investigates the association between NRBCs, RVSP, and severity of TTN. We think that elevated NRBCs and RVSP values are helpful for clinicians in decision making for referral of the patients to a secondary or a tertiary level of NICU and also inform the families about prognosis.
... One of the primary causes of illness and death in neonates is respiratory issues [22]. Before week 39, caesarean births are twice as risky, especially for moms who did not feel labor pain [23,24]. Therefore, specialists advise that for the benefit of the infants' health, cesareans should never be conducted without obstetrical grounds and should only be carried out in an emergency or after the commencement of labor pain [25]. ...
Introduction: Majority of the deaths during child birth are due to complication after delivery. C-section which is a measure to reduce death rate of the mother and fetus comes with many complications. Proper knowledge should be provided to the child bearing mother to choose the right method of delivery. Aim of the study: The aim of this study was to compare the post-operative complications among patients undergoing cesarean section vs normal vaginal delivery. Methods: This cross-sectional study was conducted in department of obstetrics & gynaecology, Janaki Medical College Teaching Hospital, Ramdaiya Bhawadi, Janakpurdham, Nepal, during the period from January 2020 to December 2022. Total 500 women who have given birth through vaginal delivery or cesarean section were included in this study. Result: Mean age of the study people in vaginal delivery group and cesarean section was 29.3 years (SD±7.5 years) and 30.9 years (SD±8.5 years) respectively. Maternal mortality was higher in cesarian section. Muscular pain was the commonest maternal complications in both vaginal delivery group and cesarean section group; 35.6% and 44.4% respectively. There was significant difference (p<0.05) between groups in muscular pain, problem in digestion, urinary trac infection, wound infection and SUI and other values were not statistically significant. In vaginal delivery group, 7.6% new born were admitted to NICU and in cesarean section group it was 11.6%. Delivery injury was commonest complication of neonatal in vaginal delivery group and RDS was commonest complication of neonatal in cesarean section group. Conclusion: For both maternal and neonatal cases, cesarean section has more complication than vaginal delivery. Muscular pain and headache were present in majority of the study people. Mortality rate in cesarean section is also slightly higher in this study.
... Cesarean delivery rates are increasing worldwide and are associated with adverse maternal and neonatal outcomes. [1][2][3][4][5] In the United States, cesarean delivery is the most frequently performed major surgical procedure. 6 The rate of cesarean delivery increased from 1996 to 2009 where it peaked at 32.9% and has remained relatively stable since then, with a rate of 31.9% in 2018. ...
Aim:
The objective of this study was to compare neonatal and maternal outcomes among women with two previous cesarean deliveries who undergo trial of labor after two cesarean section (TOLA2C) versus elective repeat cesarean delivery (ERCD). Our primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes included APGAR score <7 at 5 min, TOLA2C success rate, uterine rupture, postpartum hemorrhage, maternal blood transfusion, maternal bowel and bladder injury, immediate postpartum infection, and maternal mortality.
Methods:
This retrospective cohort study was undertaken at a community medical center from January 1, 2008 to December 31, 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a previous successful TOLA2C, prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, multiple gestation, nonvertex presentation, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test.
Results:
A total of 793 patients fulfilled study criteria. There were no differences in neonatal intensive care unit admissions or 5-min APGAR scores <7 between the two groups. Sixty-eight percent of women who underwent TOLAC (N = 82) had a successful vaginal delivery. The uterine rupture rate was 1.16% (N = 1) in the TOLA2C group with no case of uterine rupture in the ERCD group. No difference in maternal morbidity was noted between the two groups. No maternal or neonatal mortalities occurred in either group.
Conclusions:
There was no difference in maternal or neonatal morbidity among patients in our study population with two previous cesarean sections who opted for TOLA2C versus ERCD.
... 17 Caesarean section predisposes the neonate to respiratory complications including RDS and transient tachypnoea of the newborn. [18][19][20] This risk increases furthermore for the subgroup of children born after elective caesarean section, i.e. before onset of labour. 21 Delaying the elective caesarean until 39 weeks or more appears to be an equally effective solution. ...
Background: Infants born at term by elective caesarean section are more likely to develop respiratory morbidity than infants born vaginally. Prophylactic corticosteroids in singleton preterm pregnancies accelerate lung maturation and reduce the incidence of respiratory complications. Thus, the aim of this randomized controlled trial was to assess the effect of antenatal corticosteroids on neonatal outcome among term pregnant women undergoing elective caesarean section.Methods: It was an open labelled randomized controlled trial conducted among women with term pregnancy of 37-38+6 weeks and planned for caesarean section at term and who were willing to participate in the study. We randomized 50 pregnant women into intervention group which received antenatal corticosteroids in the form of injection dexamethasone 12 mg IM, 4 doses at 12 hourly intervals before term elective caesarean section and 50 pregnant women into control group which did not receive antenatal corticosteroid. Fetal outcomes were compared in both groups after caesarean section. Data were analysed using SPSS vs.20.Results: Nearly half (54%) of pregnant women belonged age group of 21-25 years and majority (58%) of pregnant women belonged to 38-39 weeks of gestation. Out of 50 pregnant women in intervention group, only two percent neonates developed RDS, four percent neonates developed transient tachypnea of neonate (TTN) and six percent neonates required NICU admission which was lower than control group. However, difference between fetal outcomes in intervention and control group was not statistically significant (p>0.05).Conclusions: Administration of prophylactic antenatal corticosteroids before 48 hours of elective term caesarean section does not have impact on fetal outcome in our study.
... 6 Most studies report an increase in adverse maternal and neonatal outcomes following RCS. 7,8 Hence, the approach of the trial of labor after CS (TOLAC) provides the opportunity to achieve a VBAC for women with a history of one or two previous low-transverse incisions, in the absence of further risk factors. 9 This advice was promoted by several organizations including the American College of Obstetricians and Gynecologists in 2010, 10 the National Institute for Health and Care Excellence in 2013, 11 and the Italian Superior Health Institute, which released guidelines in 2012. ...
Objective
To investigate the effect of a quality improvement project with an educational/motivational intervention in northern Italy on the implementation of the trial of labor after cesarean section (CS).
Method
A pre‐post study design was used. Every birth center (n = 23) of the Emilia‐Romagna region was included. Gynecologist opinion leaders were first trained about Italian CS recommendations. Barriers to implementation were discussed and shared. Educational/motivational interventions were implemented. Data of multipara with previous CS, with a single, cephalic pregnancy at term, were collected during two periods, before (2012–2014) and after (2017–2019) the intervention (2015–2016). The primary outcome was the rate of vaginal birth after CS (VBAC) and perinatal outcomes.
Results
A total of 20 496 women were included. The VBAC rate increased from 18.1% to 23.1% after intervention (P < 0.001). The likelihood of VBAC—adjusted for age 40 years or older, Caucasian, body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) at least 30, previous vaginal delivery, and labor induction—was increased by the intervention by 42% (odds ratio 1.42, 95% confidence interval 1.31–1.54). Neonatal well‐being was improved by intervention; neonates requiring resuscitation decreased from 2.1% to 1.6% (P = 0.001).
Conclusion
Educating and motivating gynecologists toward the trial of labor after CS is worth pursuing. Health quality improvement is demonstrated by increased VBAC even improving neonatal well‐being.
... Despite the high frequency of respiratory distress within the PCD population, the likelihood of an individual newborn presenting with respiratory distress secondary to PCD is low. Term neonatal respiratory failure, irrespective of underlying diagnoses, occurs in around 2 cases per 1000 live births, typically related to disorders of transition, or infectious or inflammatory conditions (sepsis, meconium aspiration, birth asphyxia); all disorders which are primarily considered to affect the alveolus, not the conducting airway [116][117][118]. Accordingly, the majority of focus in neonates historically has been in alveolar disease; PCD reports have been confined to case series, and standard reviews of neonatal respiratory distress do not reference ciliary disorders [111,119]. ...
Motile cilia are hairlike organelles that project outward from a tissue-restricted subset of cells to direct fluid flow. During human development motile cilia guide determination of the left-right axis in the embryo, and in the fetal and neonatal periods they have essential roles in airway clearance in the respiratory tract and regulating cerebral spinal fluid flow in the brain. Dysregulation of motile cilia is best understood through the lens of the genetic disorder primary ciliary dyskinesia (PCD). PCD encompasses all genetic motile ciliopathies resulting from over 60 known genetic mutations and has a unique but often underrecognized neonatal presentation. Neonatal respiratory distress is now known to occur in the majority of patients with PCD, laterality defects are common, and very rarely brain ventricle enlargement occurs. The developmental function of motile cilia and the effect and pathophysiology of motile ciliopathies are incompletely understood in humans. In this review, we will examine the current understanding of the role of motile cilia in human development and clinical considerations when assessing the newborn for suspected motile ciliopathies.
... Higher incidence of TTNB was seen in emergency LSCS compared to elective LSCS with the trial of labor (24% vs. 0.5%). This finding is in consonance with Morrison et al. [23] and Cohen and Carson [24] where the incidence of respiratory morbidity was found to be significantly higher for subjects delivered by emergency LSCS before the onset of labor. This finding of the current study strengthens the theory of protective effects of labor against TTNB [25] and is clinically relevant, as it affirms the importance of trial of labor even in the case of elective cesarean section. ...
Background
More than 21% of births worldwide are by cesarean section (CS). CS can save lives, but it increases the risk of neonatal respiratory morbidity, especially before 39 weeks. Preterm elective CS has been linked to higher newborn respiratory distress rates. Understanding these risks is essential for optimizing CS timing to improve neonatal outcomes.
Patients and Methods
This study employed a hospital-based descriptive cross-sectional design conducted at two hospitals in Kirkuk City, Iraq, between December 2023 and February 2024. The study included 230 mothers who delivered infants between 36 and 41 weeks of gestation via elective or emergency CS or vaginal delivery. Data were collected using a structured questionnaire covering maternal medical history, gestational age, mode of delivery, and neonatal respiratory outcomes.
Results
The study found that 14.8% of neonates developed respiratory distress syndrome (RDS), and 2/3 of them experienced transient tachypnea of the newborn. Infants delivered before 37 weeks were three times more likely to develop RDS than those delivered at or after 37 weeks (odds ratio = 3.1 and P = 0.003). Elective CSs were associated with lower respiratory morbidity compared to emergency CSs. In addition, advanced maternal age was significantly linked to higher rates of neonatal respiratory distress ( P = 0.046).
Conclusion
Delaying elective CSs until 39 weeks significantly reduces the risk of neonatal respiratory distress. Infants born before 39 weeks face a higher likelihood of RDS.
e565389 https://doi.org/10.47820/recima21.v5i6.5389 PUBLICADO: 06/2024 RESUMO O objetivo deste estudo é descrever desfechos perinatais após a implementação da Lei Estadual 17.137 que permite cesárea (PC) por desejo materno. Métodos: Trata-se de uma coorte retrospectiva de mulheres que tiveram parto de agosto de 2019 a 30 de junho de 2020, na Maternidade Cidinha Bonini, Ribeirão Preto-SP, Brasil. Resultados: Foram avaliados 1.020 pares de mulheres e seus RN. A idade média das mulheres foi de 26,1±6,0 anos. Metade dos nascimentos ocorreu por via vaginal (529, 51,9%), 315 (30,8%) tiveram analgesia farmacológica durante o trabalho de parto, e 491 cesáreas, 219 (46,4%) foram por desejo materno. Não houve diferença significativa entre as complicações maternas relacionadas à via de parto. Houve mais hipoglicemia e alterações respiratórias na PC e mais tocotraumatismo no parto vaginal (PV) comparando as vias de parto. Houve mais necessidade de internação em Unidade de Cuidados Intermediários (UCI) (PV 4% vs PC 12,2%, p<0,0001) para cesárea, enquanto houve mais necessidade de fototerapia (PV 7,2% vs 3,6% PC, p<0.0001) nos RN de parto vaginal. Conclusão: Com o aumento de cesárea após a implementação de Lei 17.137, houve mais desfechos negativos neonatais e admissão de RN nascidos de cesárea comparado aos RN de partos vaginais. PALAVRAS-CHAVE: Cesárea. Assistência perinatal. Saúde materno-infantil. ABSTRACT The objective of this study is to describe perinatal outcomes after the implementation of State Law 17137, which allows cesarean sections (CP) for maternal request. Methods: This is a retrospective cohort of women who gave birth from August 2019 to June 30, 2020, at Maternidade Cidinha Bonini, Ribeirão Preto-SP, Brazil. Results: 1020 pairs of women and their newborns were evaluated. The age of women was 26.1±6.0 years. Half of the births were vaginal birth (529, 51.9%), 315 (30.8%) had pharmacological analgesia during labor, and 491 cesarean sections, 219 (46.4%) were due to maternal request. There was no significant difference between maternal complications related to the mode of delivery. There was more hypoglycemia and respiratory changes in CP and more tocotrauma in vaginal birth (PV) comparing the delivery routes. There was a greater need for hospitalization in the Intermediate Care Unit (ICU) (PV 4% vs PC 12.2%, p<0.0001) for cesarean section, while there was a greater need for phototherapy (PV 7.2% vs 3.6% PC, p<0.0001) in vaginal birth newborns. Conclusion: As the increase in cesarean sections after the implementation of Law 17,137, there were
Disorders of the cardiac rhythm may occur in both the fetus and neonate. Because of the immature myocardium, the hemodynamic consequences of either bradyarrhythmias or tachyarrhythmias may be far more significant than in mature physiological states. Treatment options are limited in the fetus and neonate because of limited vascular access, patient size, and the significant risk/benefit ratio of any intervention. In addition, exposure of the fetus or neonate to either persistent arrhythmias or antiarrhythmic medications may have yet-to-be-determined long-term developmental consequences. This scientific statement discusses the mechanism of arrhythmias, pharmacological treatment options, and distinct aspects of pharmacokinetics for the fetus and neonate. From the available current data, subjects of apparent consistency/consensus are presented, as well as future directions for research in terms of aspects of care for which evidence has not been established.
Neonatal respiratory failure (NRF) is an emergency which has not been examined extensively. We critically synthesized the contemporary in-hospital prevalence, mortality rate, predictors, aetiologies, diagnosis and management of NRF to better formulate measures to curb its burden. We searched MEDLINE and Google Scholar from 01/01/1992 to 31/12/2022 for relevant publications. We identified 237 papers from 58 high-income and low-and middle-income countries (LMICs). NRF prevalence ranged from 0.64 to 88.4% with some heterogeneity. The prevalence was highest in Africa, the Middle East and Asia. Globally as well as in Asia and the Americas, respiratory distress syndrome (RDS) was the leading aetiology of NRF. Neonatal sepsis was first aetiology in Africa, whereas in both Europe and the Middle East it was transient tachypnoea of the newborn. Independent predictors of NRF were prematurity, male gender, ethnicity, low/high birth weight, young/advanced maternal age, primiparity/multiparity, maternal smoking, pregestational/gestational diabetes mellitus, infectious anamneses, antepartum haemorrhage, gestational hypertensive disorders, multiple pregnancy, caesarean delivery, antenatal drugs, foetal distress, APGAR score, meconium-stained amniotic fluid and poor pregnancy follow-up. The NRF-related in-hospital mortality rate was 0.21–57.3%, highest in Africa, Asia and the Middle East. This death toll was primarily due to RDS globally and in all regions. Clinical evaluation using the Silverman-Anderson score was widely used and reliable. Initial resuscitation followed by specific management was the common clinical practice.
Conclusion: NRF has a high burden globally, driven by RDS, especially in LIMCs where more aggressive treatment and innovations, preferably subsidized, are warranted to curb its alarming burden. What is Known:
• Neonatal respiratory failure is a frequent emergency associated with a significant morbidity and mortality, yet there is no comprehensive research paper summarizing its global burden.
• Neonatal respiratory failure needs prompt diagnosis and treatment geared at improving neonatal survival.
What is New:
• Neonatal respiratory failure has an alarmingly high global burden largely attributed to Respiratory distress syndrome. Low resource settings are disproportionately affected by the burden of neonatal respiratory failure.
• Independent preditors of neonatal respiratory failure are several but can be classified into foetal, maternal and obstetrical factors. An illustrative pedagogical algorithm is provided to facilitate diagnosis and management of neonatal respiratory failure by healthcare providers.
Elective cesarean delivery on maternal request is a challenging topic of discussion for patients, their families, and clinicians. Efforts to reduce the rate of cesarean deliveries should include the proportion of cesarean deliveries at term that occur solely due to maternal request rather than a maternal or fetal indication. Additionally, clinicians should follow good clinical practice, which includes family counseling, discussions on the benefits and potential risks of elective cesarean delivery, timing of delivery, and ethical and legal considerations. Furthermore, there is the need for a sustained workforce of perinatal clinicians and staff trained in the appropriate technique and management of operative complications. This article reviews global rates of elective cesarean on maternal request and outlines FIGO's good practice recommendations for counseling expectant mothers and the conduct of elective cesarean versus vaginal delivery.
Objective This study aimed to evaluate the timing of elective cesarean sections at 37 to 41 weeks from a tertiary hospital in Japan. The primary outcome was the rate of adverse neonatal outcomes, especially focusing on neonates delivered at 38 weeks of gestation.
Study Design The study population was drawn from singleton pregnancies delivered following planned cesarean birth at the Fukuda Hospital from 2012 to 2019. Information on deliveries was obtained from the hospital database, which contains clinical, administrative, laboratory, and operating room databases.
Results After excluding women with chronic conditions, maternal complications, indications for multiple births, or a neonate with an anomaly, 2,208 neonates remained in the analysis. Among adverse neonatal outcomes, the rate was significantly higher in neonates delivered at 37 weeks of gestation (unadjusted odds ratio [OR] = 13.22 [95% confidence interval [CI]: 6.28, 27.86], p < 0.001) or 38 weeks of gestation (unadjusted OR = 1.82 [95% CI: 1.04, 3.19], p = 0.036) compared with neonates delivered at 39 to 41 weeks. The adjusted risk of any adverse outcome was significantly higher at 380–1/7 weeks (adjusted OR = 2.40 [95% CI: 1.35, 4.30], p = 0.003) and 382–3/7 weeks (adjusted OR = 1.89 [95% CI: 1.04, 3.44], p = 0.038) compared with neonates delivered at 39 to 41 weeks, respectively.
Conclusion Our findings suggest that elective cesarean sections might be best scheduled at 39 weeks or later. When considering a cesarean at 38 weeks, it appears that 384/7 weeks of gestation or later could be a preferable timing in the context of reducing neonatal risks. However, as the composite outcome includes mostly minor conditions, the clinical significance of this finding needs to be carefully interpreted.
Key Points
Objective: To assess and compare the effect of Salbutamol and Furosemide therapy in the management of transient tachypnea of newborn. Study Design: Randomized controlled trial (Registered with Clinical Trials.gov: NCT03208894). Place and Duration of Study: Neonatal Intensive Care Unit of Pakistan Emirates Military Hospital Rawalpindi from Oct 2019 to May 2020. Methodology: A total of 100 newborns were included in the study. They were divided into 4 groups. Group-A received nebulized 0.1ml Salbutamol. Group-B was given single intravenous dose of injection Furosemide at the dose of 2mg per kg. Group-C received both IV Furosemide and nebulized Salbutamol. Control group-D received only supportive care. Results: There were 48 male babies and 52 female babies. The average gestational age was 38.8 ± 6.2 weeks and the average birth weight was 2558 ± 620 grams. Administration of both Salbutamol and IV Furosemide together (group-C) showed significant reduction in the mean duration of oxygen dependency compared to control-group (13.40 ± 3.342 vs 83.64 ± 68.546 hours respectively (p<0.001), as well as the need for mechanical ventilation. The mean duration of oxygen dependency in other two groups (A and B) were also reduced compared to control group, but the results were not statistically significant. Conclusion: Salbutamol and Furosemide when given together tend to reduce the duration of oxygen dependency and need for invasive mechanical ventilation in babies with transient tachypnea of newborn.
Objectives
To assess the feasibility of conducting a randomised placebo-controlled trial of corticosteroids prior to planned caesarean section from 35 ⁺⁰ to 39 ⁺⁶ weeks.
Design
A triple-blind, placebo-controlled, parallel, trial randomised at the participant level (1:1 ratio). Additional feasibility data obtained by questionnaires from trial participants and women who declined trial participation, and focus groups with local site researchers and clinicians.
Setting
Three obstetric units in New Zealand including tertiary and secondary care; public and private care, and research active and non-active units.
Participants
Women undergoing a planned caesarean section from 35 ⁺⁰ to 39 ⁺⁶ weeks; local site researchers and clinicians.
Interventions
Two doses of 11.4 mg betamethasone or saline placebo. Questionnaires and focus group meetings.
Primary and secondary outcome measures
Primary outcome: trial recruitment rate of eligible women. Secondary outcomes: trial recruitment by gestational age, site and delivery indication; proportion of babies who completed measurements of blood glucose concentrations as per protocol; overall incidence neonatal respiratory distress requiring >60 min of respiratory support; overall incidence of neonatal hypoglycaemia, and barriers and enablers to trial participation by participants, researchers and clinicians.
Results
The recruitment rate was 8.9% (88/987) overall and 11.2% (88/789) for those approached about the trial. Neonatal blood glucose concentrations were measured as per protocol in 87/92 (94.6%) babies. For potential participants, key enablers to participation were contributing to research, a feeling of relevance and a good understanding; key barriers were a lack of understanding and concerns over safety. For researchers and clinicians, themes representing enablers and barriers included relevance, communication and awareness, influences on women’s decision-making, resource challenges and trial process practicalities.
Conclusions
Some women are willing to participate in a randomised placebo-controlled trial of corticosteroids prior to a planned caesarean section birth at late preterm and term gestations. Participation in such a trial can be enhanced.
Introducción: Los recién nacidos a término precoz tienen mayor riesgo de complicaciones y morbilidad que los neonatos a término tardío. El objetivo fue determinar la incidencia de recién nacidos a término precoz en el Hospital Hipólito Unanue de Tacna. Material y Método: Estudio descriptivo, retrospectivo, de corte transversal. Se analizó 10587 recién nacidos vivos con edad gestacional de 37 a 38 semanas, de embarazo único, nacidos en el hospital Hipólito Unanue de Tacna durante los años 2000 a 2013. SE presenta incidencia por año. Se utilizó base de datos del Sistema Informático Perinatal. Resultados: Durante los años 2000 a 2013 en el hospital Hipólito Unanue de Tacna, se atendieron 46783 recién nacidos vivos, de los cuales 22,6% fueron a término precoz, lo que representan 25% de todos los a término. La incidencia oscila entre 19,7% en el año 2000, hasta el 24,6% en el año 2013, con discreta tendencia ascendente. Conclusión: La incidencia de recién nacidos a término precoz en el Hospital Hipólito Unanue de Tacna se encuentra en el promedio nacional e internacional.
The breech position is a variant of presentation, which occurs in ca. 3–6% of pregnancies at term. After prenatal counseling and shared decision-making, first an external cephalic version and thereafter a cesarean section (planned or at onset of labor) or a vaginal delivery from the breech position can be offered. At present a vaginal delivery is only possible and safe in specialized and designated departments. The quality of care is dependent on various factors: selection of a suitable candidate, wide experience of the involved obstetrician and midwives and written guidelines. An upright delivery position is advantageous in breech presentation and leads to a physiological spontaneous birth in approximately half of the cases. This article focuses on the management of breech presetation in uncomplicated pregnancy at term in the presence of a breech position.
Background Pregnant women are currently offered two ultrasound scans, one at booking (around 12 weeks’ gestation) and one at around 20 weeks’ gestation. No further scans are offered unless there are clinical indications. Ultrasound has an important role in the management of high-risk pregnancies. However, there is no clear evidence that it is effective in screening low risk and unselected women. The majority of complications, such as stillbirth and shoulder dystocia occur in low-risk pregnancies, first because most pregnancies are classified as low-risk and second, possibly due to inadequate screening. An effective ultrasound screening programme in late pregnancy combined with an intervention, like induction of labour, for the screen positives could potentially improve pregnancy outcomes. However, the diagnostic accuracy of many ultrasonic features is unknown in low-risk populations and there is a possibility of iatrogenic harm by intervening when it is not necessary. Objectives 1. To assess the diagnostic effectiveness of late pregnancy ultrasound in nulliparous women based on the existing research literature. 2. To analyse the prospective cohort study, Pregnancy Outcome Prediction Study, for the above ultrasound findings and combine the results with the meta-analyses. 3. Finally, use the results to provide inputs for health economic analyses of the cost-effectiveness of universal ultrasound screening and assess the need, potential design, and acceptability of a future randomised controlled trial. Methods The following key ultrasound measurements were identified which might be used in late pregnancy screening: (i) suspected small for gestational age (SGA), (ii) suspected large for gestational age (LGA), (iii) high resistance pattern of umbilical artery Doppler flow velocimetry, (iv) low cerebro-placental ratio (CPR), (v) severe oligohydramnios, (vi) borderline oligohydramnios. I found that there was an on-going Cochrane Diagnostic Test Accuracy review for SGA, hence I focused on the other five measures. The protocol was registered with the PROSPERO register of systematic reviews (CRD42017064093). Medline, EMBASE, Clinical Trials.gov and the Cochrane library were searched from inception. Studies that performed an ultrasound scan ≥24 weeks of gestational age in unselected, low or mixed risk populations were included, excluding studies which only included high risk pregnancies. The risk of bias in each included study was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS 2) tool. Meta-analysis was performed using the hierarchal summary receiver operating characteristic curve (HSROC) analysis and bivariate logit-normal models. I also performed new analyses on previously unpublished data of the Pregnancy Outcome Prediction (POP) study which was one of the few studies that blinded ultrasound scan results to the clinicians. Results 41 studies of LGA met our inclusion criteria involving 112,034 patients in total. Ultrasonic suspicion of fetal macrosomia was strongly predictive of the risk of delivering a large baby with the positive LRs (LR+) ranging from 7 to 12. However, it was only weakly predictive of the risk of shoulder dystocia with LR+ around 2. 13 studies of umbilical artery (UA) Doppler that met our inclusion criteria including 67,764 patients in total. UA Doppler had weak/moderate predictive accuracy for detecting SGA and severely SGA (<3rd percentile) infants (LR+ between 2.5 and 3.0). However, it did not predict neonatal morbidity at term. The results were very similar in both the POP study and the meta-analysis (which included the POP study) with the only notable difference being that the association with severe SGA in the POP study was slightly stronger. 16 studies of CPR met the inclusion criteria involving 121,607 patients in total. CPR may be slightly more predictive than UA Doppler in identifying pregnancies at an increased risk of adverse outcome. In the case of SGA, the positive LRs were in the region of 3.5 to 4.0. Moreover, unlike UA Doppler, a low level of CPR was associated with an increased risk of neonatal morbidity. However, the association with morbidity was weaker with positive LRs of <2.0. Furthermore, in both analyses, there was very significant heterogeneity in relation to both SGA and neonatal morbidity. 14 studies of severe oligohydramnios that met our inclusion criteria involving 109,679 patients in total. Diagnosis of severe oligohydramnios was associated with a positive LR for SGA of between 2.5 and 3.0. It was also associated with positive LRs for admission to NICU and emergency caesarean section for fetal distress of between 1.5 and 2.5. However, the study quality was variable and only two studies containing <5% of the patients included in the meta-analysis blinded the results of the scan. 11 studies of borderline oligohydramnios (including the POP study) met our inclusion criteria involving 37,848 patients in total. Borderline oligohydramnios was weakly/moderately predictive of SGA (positive LRs 2.5 to 3.0). This was observed in the meta-analysis of multiple studies of variable quality. There was also a comparable association between borderline oligohydramnios and severe SGA in the only study where the scan result was blinded, the POP study. Finally, by analysing of the POP cohort We identified the 4.6% of women who had a breech presentation, and for more than half of these, it had not previously been clinically suspected. Most of these women were delivered by planned Caesarean section. No woman in the cohort had a vaginal breech delivery or experienced an intrapartum Caesarean for undiagnosed breech. An introduction of a policy of third trimester ultrasound for fetal presentation would prevent about 5000 emergency Caesarean sections and 8 perinatal deaths annually in the UK. The policy would be cost-effective at a cost of £19.80 per scan. Conclusion There is a strong clinical and health economic case for implementing late pregnancy ultrasound screening to assess fetal presentation. Universal ultrasound screening for macrosomia would increase the detection of LGA infants at birth but is unlikely to increase the detection of shoulder dystocia or associated neonatal morbidity in a clinically significant way. Umbilical artery Doppler, CPR, severe oligohydramnios, and borderline oligohydramnios were all weakly predictive of the risk of delivering an SGA infant but either non-predictive or weakly predictive of the risk of neonatal morbidity. They should not be used alone to screen for neonatal morbidity, however a positive result would justify further fetal monitoring due to the association of all above markers with SGA.
Background
Transient tachypnoea of the newborn (TTN) is characterised by tachypnoea and signs of respiratory distress. It is caused by delayed clearance of lung fluid at birth. TTN typically appears within the first two hours of life in term and late preterm newborns. Although it is usually a self‐limited condition, admission to a neonatal unit is frequently required for monitoring, the provision of respiratory support, and drugs administration. These interventions might reduce respiratory distress during TTN and enhance the clearance of lung liquid. The goals are reducing the effort required to breathe, improving respiratory distress, and potentially shortening the duration of tachypnoea. However, these interventions might be associated with harm in the infant.
Objectives
The aim of this overview was to evaluate the benefits and harms of different interventions used in the management of TTN.
Methods
We searched the Cochrane Database of Systematic Reviews on 14 July 2021 for ongoing and published Cochrane Reviews on the management of TTN in term (> 37 weeks' gestation) or late preterm (34 to 36 weeks' gestation) infants. We included all published Cochrane Reviews assessing the following categories of interventions administered within the first 48 hours of life: beta‐agonists (e.g. salbutamol and epinephrine), corticosteroids, diuretics, fluid restriction, and non‐invasive respiratory support. The reviews compared the above‐mentioned interventions to placebo, no treatment, or other interventions for the management of TTN. The primary outcomes of this overview were duration of tachypnoea and the need for mechanical ventilation. Two overview authors independently checked the eligibility of the reviews retrieved by the search and extracted data from the included reviews using a predefined data extraction form. Any disagreements were resolved by discussion with a third overview author. Two overview authors independently assessed the methodological quality of the included reviews using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) tool. We used the GRADE approach to assess the certainty of evidence for effects of interventions for TTN management. As all of the included reviews reported summary of findings tables, we extracted the information already available and re‐graded the certainty of evidence of the two primary outcomes to ensure a homogeneous assessment. We provided a narrative summary of the methods and results of each of the included reviews and summarised this information using tables and figures.
Main results
We included six Cochrane Reviews, corresponding to 1134 infants enrolled in 18 trials, on the management of TTN in term and late preterm infants, assessing salbutamol (seven trials), epinephrine (one trial), budesonide (one trial), diuretics (two trials), fluid restriction (four trials), and non‐invasive respiratory support (three trials). The quality of the included reviews was high, with all of them fulfilling the critical domains of the AMSTAR 2. The certainty of the evidence was very low for the primary outcomes, due to the imprecision of the estimates (few, small included studies) and unclear or high risk of bias.
Salbutamol may reduce the duration of tachypnoea compared to placebo (mean difference (MD) −16.83 hours, 95% confidence interval (CI) −22.42 to −11.23, 2 studies, 120 infants, low certainty evidence). We did not identify any review that compared epinephrine or corticosteroids to placebo and reported on the duration of tachypnoea. However, one review reported on "trend of normalisation of respiratory rate", a similar outcome, and found no differences between epinephrine and placebo (effect size not reported). The evidence is very uncertain regarding the effect of diuretics compared to placebo (MD −1.28 hours, 95% CI −13.0 to 10.45, 2 studies, 100 infants, very low certainty evidence). We did not identify any review that compared fluid restriction to standard fluid rates and reported on the duration of tachypnoea. The evidence is very uncertain regarding the effect of continuous positive airway pressure (CPAP) compared to free‐flow oxygen therapy (MD −21.1 hours, 95% CI −22.9 to −19.3, 1 study, 64 infants, very low certainty evidence); the effect of nasal high‐frequency (oscillation) ventilation (NHFV) compared to CPAP (MD −4.53 hours, 95% CI −5.64 to −3.42, 1 study, 40 infants, very low certainty evidence); and the effect of nasal intermittent positive pressure ventilation (NIPPV) compared to CPAP on duration of tachypnoea (MD 4.30 hours, 95% CI −19.14 to 27.74, 1 study, 40 infants, very low certainty evidence).
Regarding the need for mechanical ventilation, the evidence is very uncertain for the effect of salbutamol compared to placebo (risk ratio (RR) 0.60, 95% CI 0.13 to 2.86, risk difference (RD) 10 fewer, 95% CI 50 fewer to 30 more per 1000, 3 studies, 254 infants, very low certainty evidence); the effect of epinephrine compared to placebo (RR 0.67, 95% CI 0.08 to 5.88, RD 70 fewer, 95% CI 460 fewer to 320 more per 1000, 1 study, 20 infants, very low certainty evidence); and the effect of corticosteroids compared to placebo (RR 0.52, 95% CI 0.05 to 5.38, RD 40 fewer, 95% CI 170 fewer to 90 more per 1000, 1 study, 49 infants, very low certainty evidence). We did not identify a review that compared diuretics to placebo and reported on the need for mechanical ventilation. The evidence is very uncertain regarding the effect of fluid restriction compared to standard fluid administration (RR 0.73, 95% CI 0.24 to 2.23, RD 20 fewer, 95% CI 70 fewer to 40 more per 1000, 3 studies, 242 infants, very low certainty evidence); the effect of CPAP compared to free‐flow oxygen (RR 0.30, 95% CI 0.01 to 6.99, RD 30 fewer, 95% CI 120 fewer to 50 more per 1000, 1 study, 64 infants, very low certainty evidence); the effect of NIPPV compared to CPAP (RR 4.00, 95% CI 0.49 to 32.72, RD 150 more, 95% CI 50 fewer to 350 more per 1000, 1 study, 40 infants, very low certainty evidence); and the effect of NHFV versus CPAP (effect not estimable, 1 study, 40 infants, very low certainty evidence).
Regarding our secondary outcomes, duration of hospital stay was the only outcome reported in all of the included reviews. One trial on fluid restriction reported a lower duration of hospitalisation in the restricted‐fluids group, but with very low certainty of evidence. The evidence was very uncertain for the effects on secondary outcomes for the other five reviews. Data on potential harms were scarce, as all of the trials were underpowered to detect possible increases in adverse events such as pneumothorax, arrhythmias, and electrolyte imbalances. No adverse effects were reported for salbutamol; however, this medication is known to carry a risk of tachycardia, tremor, and hypokalaemia in other settings.
Authors' conclusions
This overview summarises the evidence from six Cochrane Reviews of randomised trials regarding the effects of postnatal interventions in the management of TTN. Salbutamol may reduce the duration of tachypnoea slightly. We are uncertain as to whether salbutamol reduces the need for mechanical ventilation. We are uncertain whether epinephrine, corticosteroids, diuretics, fluid restriction, or non‐invasive respiratory support reduces the duration of tachypnoea and the need for mechanical ventilation, due to the extremely limited evidence available. Data on harms were lacking.
Background:
Infants born at term by elective caesarean section are more likely to develop respiratory morbidity than infants born vaginally. Prophylactic corticosteroids in singleton preterm pregnancies accelerate lung maturation and reduce the incidence of respiratory complications. It is unclear whether administration at term gestations, prior to caesarean section, improves the respiratory outcomes for these babies without causing any unnecessary morbidity to the mother or the infant.
Objectives:
The objective of this review was to assess the effect of prophylactic corticosteroid administration before elective caesarean section at term, as compared to usual care (which could be placebo or no treatment), on fetal, neonatal and maternal morbidity. We also assessed the impact of the treatment on the child in later life.
Search methods:
For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov (20 January 2021) and reference lists of retrieved studies.
Selection criteria:
We included randomised controlled trials comparing prophylactic antenatal corticosteroid administration (betamethasone or dexamethasone) with placebo or with no treatment, given before elective caesarean section at term (at or after 37 weeks of gestation). Quasi-randomised and cluster-randomised controlled trials were also eligible for inclusion.
Data collection and analysis:
We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two review authors independently assessed trials for inclusion, assessed risk of bias, evaluated trustworthiness (based on predefined criteria developed by Cochrane Pregnancy and Childbirth), extracted data and checked them for accuracy and assessed the certainty of the evidence using the GRADE approach. Our primary outcomes were respiratory distress syndrome (RDS), transient tachypnoea of the neonate (TTN), admission to neonatal special care for respiratory morbidity and need for mechanical ventilation. We planned to perform subgroup analyses for the primary outcomes according to gestational age at randomisation and type of corticosteroid (betamethasone or dexamethasone). We also planned to perform sensitivity analysis, including only studies at low risk of bias.
Main results:
We included one trial in which participants were randomised to receive either betamethasone or usual care. The trial included 942 women and 942 neonates recruited from 10 UK hospitals between 1995 and 2002. This review includes only trials that met predefined criteria for trustworthiness. We removed three trials from the analysis that were included in the previous version of this review. The risk of bias was low for random sequence generation, allocation concealment and incomplete outcome data. The risk of bias for selective outcome reporting was unclear because there was no published trial protocol, and therefore it is unclear whether all the planned outcomes were reported in full. Due to a lack of blinding we judged there to be high risk of performance bias and detection bias. We downgraded the certainty of the evidence because of concerns about risk of bias and because of imprecision due to low event rates and wide 95% confidence intervals (CIs), which are consistent with possible benefit and possible harm Compared with usual care, it is uncertain if antenatal corticosteroids reduce the risk of RDS (relative risk (RR) 0.34 95% CI 0.07 to 1.65; 1 study; 942 infants) or TTN (RR 0.52, 95% CI 0.25 to 1.11; 1 study; 938 infants) because the certainty of evidence is low and the 95% CIs are consistent with possible benefit and possible harm. Antenatal corticosteroids probably reduce the risk of admission to neonatal special care for respiratory complications, compared with usual care (RR 0.45, 95% CI 0.22 to 0.90; 1 study; 942 infants; moderate-certainty evidence). The proportion of infants admitted to neonatal special care for respiratory morbidity after treatment with antenatal corticosteroids was 2.3% compared with 5.1% in the usual care group. It is uncertain if antenatal steroids have any effect on the risk of needing mechanical ventilation, compared with usual care (RR 4.07, 95% CI 0.46 to 36.27; 1 study; 942 infants; very low-certainty evidence). The effect of antenatal corticosteroids on the maternal development of postpartum infection/pyrexia in the first 72 hours is unclear due to the very low certainty of the evidence; one study (942 women) reported zero cases. The included studies did not report any data for neonatal hypoglycaemia or maternal mortality/severe mortality.
Authors' conclusions:
Evidence from one randomised controlled trial suggests that prophylactic corticosteroids before elective caesarean section at term probably reduces admission to the neonatal intensive care unit for respiratory morbidity. It is uncertain if administration of antenatal corticosteroids reduces the rates of respiratory distress syndrome (RDS) or transient tachypnoea of the neonate (TTN). The overall certainty of the evidence for the primary outcomes was found to be low or very low, apart from the outcome of admission to neonatal special care (all levels) for respiratory morbidity, for which the evidence was of moderate certainty. Therefore, there is currently insufficient data to draw any firm conclusions. More evidence is needed to investigate the effect of prophylactic antenatal corticosteroids on the incidence of recognised respiratory morbidity such as RDS. Any future trials should assess the balance between respiratory benefit and potential immediate adverse effects (e.g. hypoglycaemia) and long-term adverse effects (e.g. academic performance) for the infant. There is very limited information on maternal health outcomes to provide any assurances that corticosteroids do not pose any increased risk of harm to the mother. Further research should consider investigating the effectiveness of antenatal steroids at different gestational ages prior to caesarean section. There are nine potentially eligible studies that are currently ongoing and could be included in future updates of this review.
ResearchGate has not been able to resolve any references for this publication.