Adherence of Obstetrician to the Guideline Regarding the Timing of Elective Caesarean Sections and its Effect on the Neonatal Outcome

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Obstet Gynecol Res 2019; 2 (3): 050-058 DOI: 10.26502/ogr021
Obstetrics and Gynecology Research Vol. 2 No. 3 – September 2019. 50
Research Article
Adherence of Obstetrician to the Guideline Regarding the Timing of
Elective Caesarean Sections and its Effect on the Neonatal Outcome
Maysara Mohammed Al-Badran1*, Maha Saleh Falgoos2
1Department of Obstetrics and Gynecology, College of medicine, University of Basra, Basra, Iraq
2Al Mawani hospital, Basra city, Iraq
*Corresponding Author: Maysara Mohammed Al-Badran, Department of Obstetrics and Gynecology, College
of medicine, University of Basra, Basra, Iraq, Tel: 9647712045056; E-mail: maysaram1979@gmail.com
Received: 24 July 2019; Accepted: 01 August 2019; Published: 23 September 2019
Citation: Maysara Mohammed Al-Badran, Maha Saleh Falgoos. Adherence of Obstetrician to the Guideline
Regarding the Timing of Elective Caesarean Sections and its Effect on the Neonatal Outcome. Obstetrics and
Gynecology Research 2 (2019): 050-058.
Abstract
Objectives:
• Study the adherence of obstetrician to the
guideline regarding the timing of elective
caesarean sections.
• Study the effect of timing of the procedure on
the neonatal outcome.
Methods: In this cross-sectional observational study,
involved 210 pregnant women who underwent elective
caesarean section that subdivided into two groups
according to gestational age at the time of caesarean
section:
• Group A: < 39 weeks.
• Group B: ≥ 39 weeks.
All neonates were examined by Pediatrician; neonates
who required admission to the NCU were followed up
until discharge.
Results: 66.7% of elective caesarean section were
performed <39week gestation and remaining (33.3%)
were performed at >39 weeks gestation. The commonest
indication of caesarean section in all gestational age was
previous scar (s) followed by malpresentation. There
was statistically higher admission to NCU among
neonates who were delivered before 39 weeks
gestation.There were 5 cases of neonatal death among
neonates who were delivered before 39 weeks. No case
of neonatal death occurs among those who were
delivered at or after 39 weeks gestation.

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Obstetrics and Gynecology Research Vol. 2 No. 3 - September2019. 51
Conclusion: There is a high proportion of elective
caesarean sections performed at earlier gestation than
recommended by guideline. This was associated with
increased neonatal mortality and morbidity.
Keywords: Cesarean section; Gestational age; Labor
1. Introduction
The rate of caesarean section deliveries is elevating
alarmingly throughout the world [1]. In the USA, the
rate of caesarean section in 2013 was 32.7% [2], which
is much higher than the WHO target for caesarean
section which is 10-15% [3], while in Iraq the rate of
caesarean section raised from 18.0% to 24.4% in 2008
and 2012 respectively [4]. Elective caesarean section:-
caesarean section is indicated, but there is no need to
perform it urgently, so timing of the delivery is planned
to fit the mother and the medical staff, as in
asymptomatic placenta previa, malpresentation (e.g.
brow, breech), previous vesico-vaginal or recto- vaginal
fistulae repair, or HIV infection [5].
1.1 The optimal timing of elective CS
“The Royal Australian and New Zealand College of
Obstetricians and Gynecologists” (RANZCOG) and
“the National Institute for Health and Care Excellence”
(NICE) state that the optimal time to perform planned
caesarean sections is after 39+0 weeks [6, 7]. Neonatal
morbidities as transient tachypnea of the newborn
respiratory distress syndrome, mechanical ventilation,
breastfeeding difficulties and admission to the neonatal
care units are more common in babies born by elective
caesarean section at 37+0 and 38+0 week gestation
compared to those born at 39+0 week gestation [8-11],
in addition neurological system continues to develop
through the period from 37+0 to 39+0 weeks and the
educational delay is lowest among children born at
40+0-41+0 weeks [12]. 1:12 women of low risk group
will develop spontaneous labour before the date of
elective caesarean section at ≥ 39+0 week, this most
commonly occur in women with previous history of
spontaneous preterm labour, smoking during pregnancy
and women who had two or more caesarean sections
[13]. Women with repeated caesarean sections who
subjected to urgent operation have higher incidence of
intra-operative bleeding, this result in increasing
numbers of caesarean section performed before 39
week gestation, however, it has been found that the risk
of bleeding is higher if caesarean section is performed
at 37-38 weeks compared to 39 weeks gestation [8]. So
maternal and neonatal morbidity caused by earlier
caesarean section should be balanced carefully against
the risks of spontaneous labour occurring before the
planned date [14].
1.2 Estimation of gestational age
1.2.1 Estimation of gestational age on the basis of
last menstrual period (LMP): Naegele`s rule is a
simple calculation for the estimated date of delivery
that involved adding 9 months and 7 days to the first
day of the LMP. This calculation provides an indirect
measure of the time of conception and remains the
current standard for calculating the duration of
pregnancy based on the LMP. Estimation of gestational
age based on LMP is considered to be less reliable than
sonographic examination because woman may become
pregnant on any day of her menstrual cycle, including
the first day [15].
1.2.2 Estimation of gestational age based on
ultrasound examination: Between 7 and 12 weeks
gestation, fetal crown-rump length (CRL) is used to
estimate the gestational age [16], it is the most accurate
sonographic measure (prediction of accuracy ± 5 days)
[17], in the period between 15 and 22 weeks the
biparietal diameter (BPD) or the head circumference
(HC) is used. Between 13 and 15 weeks, ultrasound
dating is less accurate, as the fetus flexes, making

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Obstetrics and Gynecology Research Vol. 2 No. 3 - September2019. 52
difficulty in measuring CRL, also it is too early for an
accurate measurement of the head (BPD, HC) [16].
1.3 Neonatal outcome
The adverse events of the neonates result from early
caesarean section include hypoglycemia, neonatal
respiratory morbidity (TTN and RDS), neonatal
intensive care unit (NICU) admissions, sepsis and
prolonged hospitalization [18]. Transient tachypnoea of
the newborn: is the most common complication after
term CS deliveries, it characterized by early onset of
tachypnoea, expiratory grunting and cyanosis, chest X-
ray is usually clear. TTN is usually managed by 40%
oxygen supply and recovery usually occur within few
days [19]. Respiratory Distress Syndrome:
predominantly affects preterm infants, however, term
infants also can be affected mainly those of diabetic
mother or after planned caesarean section, it manifested
by tachypnoea, cyanosis, prominent grunting and nasal
flaring. Chest X-ray shows a ground-glass appearance
with air bronchograms [20].
2. Patients and Methods
This is a cross- sectional observational study carried out
at Al-Mawany hospital, Al-Basra, Iraq through a period
extended from January till July 2017. A total of 210
pregnant women who underwent elective cesarean
delivery were involved in the study. All the studied
women were collected from the obstetric ward. Pregnant
women involved in this study were subdivided into two
groups:
• Group A (n=140): include pregnant women
with gestational Age of less than 39weeks at
the time of caesarean section.
• Group B (n=70): those with gestational age of
39 weeks or more at the time of elective
caesarean section.
Detailed history was obtained from all participants,
including age, gravidity and parity, details of the present
pregnancy, surgical history; if there is previous
caesarean section and any medical disease. Gestational
age was determined by the date of the last menstrual
period and the results of earlier ultrasound examination.
Women with diabetes mellitus, gestational or chronic
hypertensive disorders, hemoglobinpathy, and multiple
pregnancies, pregnancies with intrauterine growth
retardation and congenital anomalies were excluded
from the study. Full clinical examination was done
including Leopold's Manoeuvers. At the time of
caesarean section, all neonates were examined by
Pediatrician, body weight and Apgar score at 1, 5 and
10 minutes was recorded. Neonates who required
admission to the NCU were followed up until discharge.
neonatal outcome, including: transient tachypnoea of
the newborn (TTN), respiratory distress syndrome
(RDS), feeding difficulties, prolonged hospitalization (5
days or longer) due to respiratory distress and death
were recorded.
2.1 Statistics analysis
Data were analyzed using NCSS11, Quantitative
variables as age, parity, fetal weight and Apgar score
were expressed as mean and SD (standard deviation),
with unpaired t-test used for comparison, Qualitative
variable were expressed as frequency and percentages
and compared by using Chi-square test. Statistically
significant differences were considered when P values
are less than 0.05.
3. Results
3.1 Maternal and fetal demographic data
Table 1 shows maternal and fetal demographic data in
both groups, maternal age and parity expressed as Mean
± SD; while fetal weight expressed as percentage. There
was statistically significant difference in maternal age
and parity between the two groups, women of group B

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Obstetrics and Gynecology Research Vol. 2 No. 3 - September2019. 53
tend to be younger and of lower parity compared to
group A. Regarding fetal weight there was statistically
significant difference between the two groups, 69.3% of
neonates born before 39 weeks gestation has body
weight of <3000 g compared to only 40% in those born
after 39 weeks gestation.
3.1 Indications of caesarean section
Table 2 shows that Previous cesarean section (s) was the
commonest indication of elective cesarean section in
both groups which accounted for 62.1% in group A and
47.1% in group B. 24.3% of women who underwent
caesarean section before 39 week gestation had 3 or
more previous caesarean sections compared to only
7.1% of those who underwent caesarean section at or
after 39 week gestation which is statistically significant
difference (P =0.0048). Caesarean section due to
malpresentation is statistically higher in group B
compared to group A (37.1% and 14.3% respectively).
Other indications which included bad obstetric history,
orthopedic surgeries and anterior–posterior vaginal wall
repair account for 22.9% of women of group A and
14.3% of women of group B.
3.2 Gestational age distribution among various
indications of elective caesarean section
Table 3 shows 66.7% of elective caesarean section were
performed at gestational age of less than 39 week [7.1%
at 36 -36+6 week, 30.5 % at 37-37+6 week and 29% at
38-38+6 week] and only 33.3% of elective caesarean
section were performed at ≥ 39 weeks gestation. The
commonest indication for caesarean section in all
gestational age was previous caesarean section (s), 80%
of caesarean section at 36 week was due to previous
scar (s), mainly three or more scares (33.3%), previous
two caesarean section was the commonest cause for
performing caesarean section at 38 week gestation,
37.1% of elective caesarean section at ≥ 39 week
gestation was due to malpresentation.
3.3 Neonatal outcome according to gestational age
Table 4 shows there was significantly higher admission
to the NCU among neonates who delivered before
39week compared to those who delivered at >39 week
(23.6% and 10% respectively). The commonest cause
for admission in both groups was TTN (11.4% in group
A and 5.7% in group B), the second commonest cause
for admission was RDS which occur more frequently in
group A (5.7%) than group B (1.4%), but this difference
didn't reach statistical significance. Four cases of RDS
required hospitalization for >5 days and treated by
oxygen supplement with no need for mechanical
ventilation, these cases belong to group of neonates who
were delivered before 39 week gestation. Statistically,
there was no significant difference in the frequency of
hypoglycemia (due to breastfeeding difficulty) between
group A and B. There were 5 cases of neonatal death
(2.4% of total number of caesarean section), all of them
occur among neonates who were delivered before 39
week gestation, three of them (1.4%) occurred among
neonates who were delivered at 37 weeks gestation, one
neonatal death occur among neonates delivered at 36
weeks and one at 38 weeks gestation.There was no
statistically significant difference in Apgar score
between both groups.
.

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AGE (Years)
Group A
Group B
P value
29.23 ± 6.70
25.84 ± 6.67
0.001
Parity
2.58 ± 1.90
1.16 ± 1.51
<0.0001
Fetal weight (g)
3.07 ± 0.39
3.36 ± 0.37
<0.0001
3000≥
97 (69.3%)
28 (40%)
0.0001
>3000
43 (31.7%)
42 (60%)
Group A: gestational Age <39weeks; Group B: gestational Age ≥ 39 weeks; P value <0.05 consider significant
Table 1: Maternal and fetal demographic data.
Malpresentation
Group A (n) %
N=140
Group B (n) %
N=70
P value
(20) 14.3%
(26) 37.1%
0.0003
Previous scar
(87) 62.1%
(33) 47.1%
0.0545
CS1
(18) 12.9%
(18) 25.7%
0.0327
CS2
(35) 25%
(10) 14.3%
0.1084
CS3≥
(34) 24.3%
(5) 7.1%
0.0048
Patient's request
(1) 0.71%
(1) 1.43%
0.8017
Other causes
(32) 22.9%
(10) 14.3%
0.2002
Group A: gestational Age <39weeks; Group B: gestational Age ≥ 39 weeks; P value <0.05 consider significant; CS-
Caesarean section
Table 2: Indications of Caesarean section in both groups.
Number of cases
36-36wk+6days
37-37wk+6days
38-38wk+6days
≥39wk
P value
(15) 7.1%
(64) 30.5%
(61) 29.1%
(70) 33.3%
< 0.0001
Malpresentation
(1) 6.7%
(10) 15.6%
(9) 14.8%
(26) 37.1%
0.0020
Previous scar
(12) 80%
(46) 71.9%
(42) 68.9%
(33) 47.1%
0.0033
CS1
(4) 26.7%
(11) 17.2%
(16) 26.2%
(18) 25.7%
0.5824
CS2
(3) 20%
(15) 23.4%
(17) 27.9%
(10) 14.2%
0.2844
CS3≥
(5) 33.3%
(20) 31.3%
(9) 14.8%
(5) 7.1%
0.0014
Patient's
request
(0) 0%
(1) 1.6%
(0) 0%
(1) 1.43%
0.7662
Other causes
(2) 13.3
(7) 10.9%
(10) 16.3
(10) 14.3%
0.3264
P value <0.05 consider as significant; Total number of cases=210
Table 3: Gestational age distribution at time of caesarean section among various indications.

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Admission to NCU
Group A (n) %
N=140
Group B (n) %
N=70
P value
(33) 23.6%
(7) 10%
0.0277
Causes of NCU Admission
RDS
(8) 5.7%
(1) 1.4%
0.187
TTN
(16) 11.4%
(4) 5.7%
0.1989
Hypoglycemia
(4) 2.8%
(3) 4.3%
0.5886
Neonatal death
(5) 3.6%
(0) 0%
0.2442
APGAR score at 1minute
6.09 ± 1.59
6.76 ± 1.07
0.2961
APGAR score at 5minute
7.51 ± 1.51
8.17 ± 1.13
0.2831
APGAR score at >5minute
8.34 ± 1.27
8.77 ± 0.995
0.4064
Group A: gestational Age <39 weeks; Group B: gestational Age ≥ 39 weeks; P value <0.05 consider significant
Table 4: Neonatal outcome.
4. Discussion
In our study, pregnant women who underwent a
caesarean section at or after 39 week gestation are of
lower age and parity than those who had a caesarean
section before 39 week gestation, our results agree with
the study of Shamel M et al. [18] and Emily D, et al.
[21]. The explanation is that the commonest indication
for caesarean section in our study was previous
caesarean section (s), so women of low parity, who
usually also would be of younger age tend to have one
or no previous caesarean section so the timing of
elective caesarean section tend to be later (>39 week
gestation) than those with previous two or more
caesarean section (who tend to be older and of higher
parity). Neonates delivered at or after 39 week gestation
had higher body weight than those who delivered before
39 week gestation, as fetal growth continue in the range
of 24-26 g/day increment in the late third trimester [22].
Malpresentation as an indication for elective caesarean
section was more common in the group of women who
underwent caesarean section at or after 39 week
gestation compared to those who had their caesarean
section before 39 week gestation, this result is in line
with the result of Shamel M, et al. [18].
The commonest indication for caesarean section in both
groups was previous caesarean section (s), 87.2% of
women with previous >3 caesarean section (34cases out
of 39) had their caesarean section performed before 39
week gestation while only 12.8% (5 cases) of them had
their caesarean section performed at or after 39 week
gestation, 82.1% (69 out of 84 cases) of women with
history of previous two or more caesarean section had
their elective procedure performed before 39 week
gestation this is agree with the results of the study of
Emily D, et al. [21] and Glavind J, et al. [23]. This
earlier caesarean section among women with multiple
caesarean sections could be due to fear of spontaneous
labour if the procedure is performed later on with
possibility of uterine rupture [24, 25], also there is an
increased risk of unexplained stillbirth [9, 26]. 17.1% of
cases of elective caesarean section (36 out of 210) was
due to previous one caesarean section because of trend
toward elective caesarean section rather than trial of
vaginal birth after caesarean section in the developing
countries which could be due to limited training or fear
of litigation [27].

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Obstetrics and Gynecology Research Vol. 2 No. 3 - September2019. 56
In our study, 66.6% of elective caesarean section were
performed before 39 weeks of gestation (group A) and
33.3% of elective caesarean section were performed at
or after 39 weeks (groupB) (P=<0.0001), this is in
agreement with the studies of Wilmink FA et al. [9] and
Yeung K, et al. [24]. It was surprising that 7.1% of
caesarean section was performed at 36 weeks gestation
and 30.5% at 37 weeks gestation, in both gestational age
the commonest cause was previous scar (s) as we
mention previously. In our study, 23.6% of the neonate
who were delivered before 39 weeks gestation had been
admitted to the NCU compared to 10% of the neonates
who were delivered at or after 39 weeks gestation. TTN
and RDS were the commonest causes for admission to
the NCU, these were more frequent in group A than in
group B, but the difference doesn't reach statistical
significance, our results agree with the study of Tita et
al. [11].
Hypoglycemia was more common in group B, this
result disagrees with the study of Emily D et al. [21].
All cases of neonatal death occurred among the
neonates who were delivered before 39 weeks gestation,
4 out of 5 of these death occurred among neonates who
were delivered before 38 weeks gestation, the result of
our study disagree with that of Ghazala A, et al. [28]
and Wilmink F [9].
5. Conclusion
There is high proportion of elective caesarean sections
performed at earlier gestation than recommended by
guideline. This was associated with increased neonatal
mortality and morbidity.
Acknowledgement
To Medical staff of gynecology and obstetrics in al
mawani hospital.
Conflict of Interest
There was no conflict of interest.
Funding Source
The research was funded by researchers themselves.
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