Mode of delivery in the preterm gestation and maternal and neonatal outcome

Cesarean delivery is associated with lower neonatal mortality among breech pregnancies: a systematic review and meta-analysis of preterm deliveries ≤32 weeks of gestation

OBJECTIVE

To investigate the association between actual and planned modes of delivery, neonatal mortality, and short-term outcomes among preterm pregnancies ≤32 weeks of gestation.

DATA SOURCES

A systematic literature search was conducted in 3 main databases (PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to November 16, 2022. The protocol was registered in advance in the International Prospective Register of Systematic Reviews (CRD42022377870).

STUDY ELIGIBILITY CRITERIA

Eligible studies examined pregnancies ≤32nd gestational week. All infants received active care, and the outcomes were reported separately by different modes of delivery. Singleton and twin pregnancies at vertex and breech presentations were included. Studies that included pregnancies complicated with preeclampsia and abruptio placentae were excluded. Primary outcomes were neonatal mortality and intraventricular hemorrhage.

STUDY APPRAISAL AND SYNTHESIS METHODS

Articles were selected by title, abstract, and full text, and disagreements were resolved by consensus. Random effects model-based odds ratios with corresponding 95% confidence intervals were calculated for dichotomous outcomes. Risk Of Bias In Non-randomized Studies - of Interventions-I was used to assess the risk of bias.

RESULTS

A total of 19 observational studies were included involving a total of 16,042 preterm infants in this systematic review and meta-analysis. Actual cesarean delivery improves survival (odds ratio, 0.62; 95% confidence interval, 0.42-0.9) and decreases the incidence of intraventricular hemorrhage (odds ratio, 0.70; confidence interval, 0.57-0.85) compared to vaginal delivery. Planned cesarean delivery does not improve the survival of very and extremely preterm infants compared to vaginal delivery (odds ratio, 0.87; 95% confidence interval, 0.53-1.44). Subset analysis found significantly lower odds of death for singleton breech preterm deliveries born by both planned (odds ratio, 0.56; 95% confidence interval, 0.32-0.98) and actual (odds ratio, 0.34; 95% confidence interval, 0.13-0.88) cesarean delivery.

CONCLUSION

Cesarean delivery should be the mode of delivery for preterm ≤32 weeks of gestation breech births due to the higher mortality in preterm infants born via vaginal delivery.

Effect of mode of delivery on perinatal outcome in severe preterm birth: systematic review and meta-analysis

OBJECTIVE

To review the evidence on the effect of mode of delivery on perinatal outcome of fetuses born before 32 weeks' gestation.

METHODS

MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), the ClinicalTrials.gov registry and gray literature sources were searched, starting from the year 2000 to reflect contemporary practice in perinatal care. Non-randomized or randomized studies that included singleton fetuses without chromosomal abnormality or major congenital defect delivered vaginally or via Cesarean section were eligible for inclusion in the analysis. Primary outcomes were neonatal death, defined as death in the first 28 days of age, and survival to discharge. Secondary outcomes were other adverse perinatal events. The ROBINS-I tool was used to assess the risk of bias. The overall quality of evidence for the outcomes was assessed according to GRADE. Summary odds ratios (ORs) with 95% CIs were calculated, and random-effects models were used for data synthesis. Subgroup analysis was performed for delivery before 28 weeks, delivery between 28 and 32 weeks and according to fetal presentation at delivery.

RESULTS

A total of 27 retrospective studies (22 887 neonates) were included in the systematic review and meta-analysis, all of which reported on singleton pregnancies. Among cases born before 28 weeks, vaginal delivery significantly increased the risk of neonatal death of fetuses with any type of presentation (n = 1496) (OR 1.87 (95% CI, 1.05-3.35); I2  = 65%, very low quality of evidence) and of fetuses with breech presentation (n = 733) (OR 3.55 (95% CI, 2.42-5.21); I2  = 21%, moderate quality of evidence). The odds of survival to discharge were significantly decreased among fetuses with breech presentation delivered before 28 weeks (n = 646) (OR 0.36 (95% CI, 0.24-0.54); I2  = 21%, low quality of evidence). Among breech fetuses born between 28 and 32 weeks, vaginal delivery increased the odds of perinatal death (intrapartum and neonatal) (n = 1581) (OR 3.06 (95% CI, 1.47-6.35); I2  = 0%, high quality of evidence). In non-cephalic fetuses born between 24 and 32 weeks, vaginal delivery decreased the odds of survival to discharge (n = 1030) (OR 0.28 (95% CI, 0.19-0.40); I2  = 0%, moderate quality of evidence). No significant effect on mortality of mode of delivery was observed in cephalic fetuses at any gestational age.

CONCLUSIONS

This systematic review and meta-analysis suggests that vaginal delivery in severe preterm birth is associated with an increased risk of neonatal and perinatal death in breech fetuses, while no significant association was observed for cephalic fetuses. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fetal Outcomes in Preterm Cesarean Sections

Introduction

Neonatal mortality is a major challenge in low-middle-income countries. The current study was conducted to assess the association between preterm cesarean delivery and fetal outcomes.

Methods

A prospective study was conducted at the Combined Military Hospital in Peshawar, Pakistan, from October 1, 2020, to March 31, 2021. All women reporting to the hospital with a cephalic presentation and singleton pregnancies between the 27th and 34th weeks of gestation were included in the study. Pregnancies with an abnormal presentation, those diagnosed with a congenital abnormality, and those with indications for growth restriction or preterm delivery were excluded from the study. We also excluded infants delivered via vacuum or forceps. The outcomes of interest in this study included neonatal death prior to discharge, neonatal respiratory distress, sepsis, intraventricular hemorrhage (IVH), seizure, subdural hemorrhage (SDH), or appearance, pulse, grimace, activity, and respiration (APGAR) test score of less than 7 at five minutes. Maternal features including diabetes, hypertension and gestational age of delivery, parity, previous cesarean sections (CS), and last pregnancy outcomes were documented in a predefined pro forma.

Results

Our sample size consisted of 288 women, who were classified into two groups. Group A comprised 144 women who gave birth vaginally and group B consisted of 144 women who underwent CS. It was observed that women who underwent cesareans had a higher likelihood of a history of hypertension and related pathologies. It was also observed that these women had a greater likelihood of being of higher age compared to women who underwent vaginal deliveries. Neonates of women who had CS were at a greater risk of presenting with respiratory distress than those who had spontaneous vaginal deliveries.

Conclusion

Based on our findings, respiratory distress was significantly more common in babies of women who delivered via CS. However, there was no difference in neonatal outcomes in terms of IVH, seizures, SDH, and APGAR score of <7.

Benefits of the «en caul» technique for extremely preterm breech vaginal delivery

INTRODUCTION

The "en caul" technique, i.e. delivery with intact membranes, may reduce the risk of obstetric trauma in vaginal breech delivery of extreme preterm infants. We aimed at comparing perinatal mortality and morbidity among extremely preterm breech vaginal deliveries between infants delivered "en caul" and those with "ruptured membranes".

MATERIAL AND METHODS

We performed a fourteen-year retrospective study in a tertiary university center. All vaginal deliveries of singleton breech live infants with an antenatal decision of active resuscitation between 24 weeks and 27⁺⁶ weeks were included. Perinatal outcomes were compared between the "en caul" group, with intact membranes at the onset of pushing efforts and the "ruptured membranes" group, with ruptured membranes at the onset of pushing efforts. The primary outcome was perinatal mortality defined by intrapartum or neonatal death. The secondary outcomes were fetal extraction difficulties, arterial pH and 5 min Apgar score.

RESULTS

We included 52 infants in the "en caul" group and 71 in the "ruptured membranes" group. The perinatal mortality rate did not differ between the two groups (19.2% in the "en caul" group versus 28.2% in the "ruptured membranes" group, p = 0.25). The mean arterial pH at birth was higher in the « en caul » group (7.32 ± 0.1 vs 7.24 ± 0.1, p = 0.001). There were no differences between the groups for fetal extraction difficulties, especially fetal head entrapment (9.6% versus 9.9%).

CONCLUSION

Even though the "en caul" technique does not seem to decrease the perinatal mortality rate, it remains a simple technique, which could improve neonatal morbidity.

Maternal morbidity by attempted route of delivery in periviable birth

OBJECTIVE

Much of the literature on clinical decision-making regarding the optimal route of delivery for periviable birth, 23 0/7-25 6/7 weeks gestation, has focused on neonatal risks. In fact, routine cesarean delivery at these early gestational ages has not been shown to improve neonatal mortality or neurological outcomes. Neonatal risks associated with the route of delivery are well known. Conversely, there is a paucity of data on maternal morbidity associated with the route of delivery. We examined maternal morbidity according to the attempted route of delivery in women undergoing periviable birth.

STUDY DESIGN

In a secondary analysis of the Consortium on Safe Labor, a retrospective cohort study, maternal outcomes were compared between attempted vaginal delivery and planned cesarean delivery in women undergoing periviable birth. Analyses were repeated to compare maternal outcomes among actual mode of delivery (vaginal delivery versus cesarean delivery). Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) with 95% confidence intervals (95% CI), controlling for predefined covariates.

RESULTS

Of 678 women who underwent periviable birth, 558 (82.3%) and 120 (17.7%) attempted vaginal delivery and planned cesarean delivery, respectively. Of 558 women who attempted a vaginal delivery, 411 (73.7%) achieved a vaginal delivery. Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery were less likely to have endometritis (3.1 versus 15.0%; aRR 0.18, 95% CI 0.09-0.35). Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery had 7-day shorter total length of hospital stay (p < .001). Comparison of actual mode of delivery showed that women with vaginal had decreased risks of fever (2.9 versus 7.9%; aRR 0.42, 95% CI 0.20-0.90), endometritis (0.5 versus 12.4%; aRR 0.03, 95% CI 0.01-0.13), and maternal thrombosis (0.2 versus 3.0%; aRR 0.08, 95% CI 0.01-0.93) compared to cesarean delivery. Women with vaginal delivery had 3-day shorter total length of hospital stay (p < .001) compared to cesarean delivery.

CONCLUSION

The majority of women (73.7%) who attempted a vaginal delivery achieved a vaginal delivery. Attempting a vaginal delivery between 23 0/7 and 25 6/7 weeks gestation compared to a planned cesarean delivery was associated with decreased risks of maternal infectious morbidity. Deciding the route of delivery is challenging in women undergoing periviable delivery. Our analysis provides important information on short-term maternal risks when considering the risks and benefits during these discussions.

Maternal outcomes of cesarean delivery performed at early gestational ages: a systematic review and meta-analysis

OBJECTIVE

This study aimed to report maternal outcomes of preterm (<34 weeks of gestation) cesarean delivery.

DATA SOURCES

Medline, Embase, and ClinicalTrials.gov databases were searched electronically on September 1, 2020, utilizing combinations of the relevant medical subject heading terms, key words, and word variants for "cesarean delivery" and "outcome."

STUDY ELIGIBILITY CRITERIA

We included only studies reporting maternal outcomes of cesarean delivery performed at <34 weeks of gestation.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcome was a composite score of maternal surgical morbidity including maternal death, severe intrasurgical or postpartum hemorrhage, hysterectomy, need for blood transfusion, and damage to adjacent organs. Secondary outcomes were individual components of the primary outcome, need for reoperation, postsurgical infection, thromboembolism, and hysterectomy. We also performed 2 subgroup analyses considering cesarean delivery performed at <28 and <26 weeks of gestation. Meta-analyses of proportions using random effects model were used to combine data.

RESULTS

A total of 15 studies involving 8378 women undergoing cesarean delivery at <34 weeks of gestation were included in the systematic review. Composite adverse maternal outcome was reported in 16.2% of women (95% confidence interval, 15.4-17.0) undergoing a cesarean delivery before 34 weeks of gestation. Hemorrhage, either intra- or postoperative, was observed in 6.9% of cases (95% confidence interval, 6.4-7.5), whereas 6.3% (95% confidence interval, 4.2-8.7) required blood transfusion. Damage to adjacent organs complicated the primary surgery in 2.0% of women (95% confidence interval, 0.1-6.4), whereas 1.2% (95% confidence interval, 0.3-3.4) required a reoperation after cesarean delivery. Maternal death occurred in 0.1% (95% confidence interval, 0.0-1.4). In women undergoing cesarean delivery at <28 weeks of gestation, composite adverse maternal outcome complicated 22.9% of cases (95% confidence interval, 16.7-33.8) and 14.0% (95% confidence interval, 5.8-24.9) experienced hemorrhage whereas 7.7% (95% confidence interval, 4.4-11.8) required blood transfusion. Finally, when considering women undergoing cesarean delivery at <26 weeks of gestation, composite adverse maternal outcome was reported in 24.8% (95% confidence interval, 10.1-43.4), whereas the corresponding figures for hemorrhage and need for blood transfusion were 9.2% (95% confidence interval, 1.7-21.6) and 6.1% (95% confidence interval, 0.3-10.0), respectively.

CONCLUSION

Early cesarean delivery is affected by a high rate of maternal intra- and postoperative complications. The findings from systematic review can help clinicians in counseling parents when cesarean delivery is required in an early gestational age.

Caesarean section and neonatal survival and neurodevelopmental impairments in preterm singleton neonates

Introduction

Evidence is lacking regarding the benefit of caesarean section (CS) for long-term neurodevelopmental outcomes in singleton preterm neonates. Therefore, uncertainty remains regarding obstetrical best practice in the delivery of premature neonates.

Objective

Our objective was to determine the association between the mode of delivery and neurodevelopmental outcomes in preterm singleton neonates who were delivered by vaginal route (VR), CS with labour (CS-L), or CS without labour (CS-NL).

Methods

Singleton neonates of less than 29 weeks' gestation born January 1995 through December 2010 and admitted to our NICU and then assessed at neonatal follow-up clinic were studied. The primary outcome was neurodevelopmental impairment (NDI) defined as cerebral palsy, cognitive delay, major or minor visual impairment, or hearing impairment or deafness at 36 months' corrected age.

Results

In this retrospective cohort study of 1,452 neonates, 1,000 were eligible for the study and 881 (88.1%) were available for follow-up. There was no significant difference in mortality between VR group, CS-L group, and CS-NL group. At 3 years, there was no significant difference between the three groups in terms of NDI. The odds of composite outcome of mortality or NDI for neonates born via CS-NL versus VR, and CS-L versus VR were 0.90 (95% confidence interval [CI]: 0.59 to 1.37) and 1.08 (95% CI: 0.72 to 1.61), respectively. Propensity score-based matched-pair analyses did not show a significant association between the composite outcome and CS with or without labour.

Conclusions

CS was not associated with increased survival or decreased risk of NDI in premature singleton neonates born at less than 29 weeks' gestation.

A 10 year comparative study of caesarean deliveries using the Robson 10 group classification system in a university hospital in Austria

OBJECTIVE

The Robson ten group classification system is used as a global standard for assessing, monitoring and comparing caesarean delivery (CD) rates within and between maternity services. Our objective was to compare the changes of CD rates at our institution between the years 2008-2010 and 2017-2019 using the Robson ten group classification system.

STUDY DESIGN

Data was collected retrospectively and all women were classified using the obstetric concepts and parameters described in the Robson ten group classification system.

RESULTS

During 2008-2010 7,832 deliveries were performed, increasing to 9,490 in 2017-2019. The CD rate also increased from 29.1% to 32.2% (p<.05) during this 10 year period. In both observed periods group 5 (single cephalic multiparous women at term with a previous CD) was the largest contributor to the overall CD rate accounting for 20.2% of all CD during 2008-2010 and increasing to 26.9% in 2017-2019 (p<.001). The overall size of group 5 also increased from 8.3% to 11.6% (p<.001). Furthermore, an increase in CD rate in group 7 (multiparous women with a single breech pregnancy, including women with a uterine scar) from 92.9% to 98.2% (p = .752) could be observed. In group 8 (women with multiple pregnancies, including women with a uterine scar) a slight shift towards vaginal delivery (VD) can be reported with CD rates decreasing from 82% to 79.2% (p = .784). There was no observed difference with CD rates in group 1 although the group size decreased from 29.4% in 2008-2010 to 24.2% in 2017-2019 (p<.001). The CD rate in group 10 experienced a slight elevation, in 2008-2010 46.2% were delivered per CD and in 2017-2019 48.8% (p = .553). The overall size of group 10 decreased, contributing 8.9% in 2008-2010 and 8% in 2017-2019 (p<.05) to the overall birthrate.

CONCLUSION

The biggest contributors to the CD rate in our hospital remain multiparous women at term with a previous CD. The CD rates, as well as the overall size of this group, keep rising, resulting in a need to establish more effective ways to motivate women with one previous CD towards vaginal birth after caesarean delivery (VBAC). Furthermore, the CD rate in preterm deliveries is increasing and approaching 50%. This illustrates the need to discuss whether CD is the appropriate mode of delivery in half of the preterm infants.

Mode of delivery and pregnancy outcomes in preterm birth: a secondary analysis of the WHO Global and Multi-country Surveys

Many studies have been conducted to examine whether Caesarean Section (CS) or vaginal birth (VB) was optimal for better maternal and neonatal outcomes in preterm births. However, findings remain unclear. Therefore, this secondary analysis of World Health Organization Global Survey (GS) and Multi-country Survey (MCS) databases was conducted to investigate outcomes of preterm birth by mode of delivery. Our sample were women with singleton neonates (15,471 of 237 facilities from 21 countries in GS; and 15,053 of 239 facilities from 21 countries in MCS) delivered between 22 and <37 weeks of gestation. We assessed association between mode of delivery and pregnancy outcomes in singleton preterm births by multilevel logistic regression adjusted for hierarchical data. The prevalences of women with preterm birth delivered by CS were 31.0% and 36.7% in GS and MCS, respectively. Compared with VB, CS was associated with significantly increased odds of maternal intensive care unit admission, maternal near miss, and neonatal intensive care unit admission but significantly decreased odds of fresh stillbirth, and perinatal death. However, since the information on justification for mode of delivery (MOD) were not available, our results of the potential benefits and harms of CS should be carefully considered when deciding MOD in preterm births.

Prevention and Therapy of Preterm Birth. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/025, February 2019) - Part 2 with Recommendations on the Tertiary Prevention of Preterm Birth and the Management of Preterm Premature Rupture of Membranes

Aims This is an official guideline of the German Society for Gynecology and Obstetrics (DGGG), the Austrian Society for Gynecology and Obstetrics (ÖGGG) and the Swiss Society for Gynecology and Obstetrics (SGGG). The aim of this guideline is to improve the prediction, prevention and management of preterm birth based on evidence obtained from recently published scientific literature, the experience of the members of the guideline commission and the views of self-help groups. Methods The members of the participating medical societies and organizations developed Recommendations and Statements based on the international literature. The Recommendations and Statements were adopted following a formal consensus process (structured consensus conference with neutral moderation, voting done in writing using the Delphi method to achieve consensus). Recommendations Part 2 of this short version of the guideline presents Statements and Recommendations on the tertiary prevention of preterm birth and the management of preterm premature rupture of membranes.

Analysis of the caesarean section rate using the 10-Group Robson classification at Benha University Hospital, Egypt

BACKGROUND

Egypt has the third highest caesarean section rate (54%) in the world and lacks a standard classification system to analyse caesarean section rates. The World Health Organization (WHO) recommends the Robson classification as an effective caesarean section analysis and monitoring tool.

AIM

To analyse the caesarean section rate of Benha University Hospital, Egypt using the standard 10-Group Robson classification system.

METHOD

A prospective, cross-sectional study was conducted at the Benha University Hospital from 1 April to 30 June 2018. All women admitted for childbirth were categorised into Robson groups to determine the absolute and relative contribution made by each group to the overall caesarean section rate. Epi Data V.3.1 software programme was used to analyse the data.

FINDINGS

850 women gave birth during the study period, 466 (55%) by caesarean section (CS). Robson Group 5 (multiparous, term, cephalic presentation and previous caesarean section) contributed the most (36%) to the overall CS rate. 175/308 (56%) women in this group had previously undergone one caesarean section. Group 6 (all nulliparous women with single breech pregnancy) and Group10 (cephalic preterm pregnancies) were the second and the third greatest contributors toward the overall CS rate, with 4.6% and 2.8% respectively.

CONCLUSIONS

In keeping with other studies, Groups 5, 6, and 10 were the main contributors to the overall caesarean section rate. We found Robson classification to be clinically relevant and an effective tool to analyse the caesarean section rate even in settings with limited resources.

Statement by the OEGGG with Review of the Literature on the Mode of Delivery of Premature Infants at the Limit of Viability

In 2017, the Austrian Society for Paediatric and Adolescent Medicine (ÖGKJ) published a guideline on the primary care of premature infants at the limit of viability. In this guideline, it is recommended that a Caesarean section be preferred as mode of delivery with regard to an early preterm birth (22 + 0 – 24 + 6 weeks of pregnancy) due to an allegedly lower perinatal risk of cerebral haemorrhage. In contrast to this, the Austrian Society for Gynaecology and Obstetrics (OEGGG) considers there to be no clinical and scientific basis for this recommendation and the mode of delivery in the case of early preterm birth must be adapted to the individual maternal and foetal clinical situation. The international data available from the generally retrospective investigations show heterogeneous results regarding the mode of delivery. The prospective and randomised data in this regard are insufficient. A Cochrane analysis does not show any advantage in favour of a Caesarean delivery. The German-language guidelines (AWMF and Switzerland) make analogous recommendations for adapting the mode of delivery with regard to an early preterm birth individually to the respective clinical situation. In the case of an early preterm birth and a singleton in cephalic presentation, the OEGGG therefore recommends individual management of the delivery which takes the maternal and foetal clinical situation into account and also includes vaginal delivery as a mode of delivery in the clinical decision process.

[Maternal outcomes in case of cesarean before 32weeks of gestation: A retrospective observational study]

OBJECTIVES

In recent years, active neonatal care in case of prematurity leads to an increase of cesarean delivery rate. Data remains sparse on maternal morbidity induced by preterm cesareans and especially before 32 weeks of gestation. The main aim of this study was to evaluate per-partum maternal morbidity in case of cesarean performed before 32 week of gestation. As secondary objectives, we assessed post-partum maternal morbidity and factors associated with maternal morbidity.

METHODS

This is a retrospective single-center study conducted in a tertiary care unit between 2014 and 2016 including cesareans performed before 32 week of gestation in the study period. The primary outcome was a composite criterion of per partum maternal morbidity including post-partum hemorrhage, blood transfusion, general anesthesia, surgical wounds and maternal death. The secondary outcome was the post-partum maternal morbidity, defined by a composite criterion including hospitalization more than 7 days, infectious disease, wall and digestive complication and venous thromboembolic disease.

RESULTS

Two hundred and eleven women were included. Maternal morbidity occurred in 21.3% in per partum and in 20.4% in post-partum. The factors associated with per partum morbidity were low-lying placenta (OR=4.40 [1.01-19.09]) and non-fetal indication of cesarean (OR=2.10[1.01-4.42]). The factors associated with post-partum morbidity were twin-pregnancy (OR=2.90 [1.12-7.54]), general anesthesia (OR=4.19 [1.68-10.49]) and non-cephalic fetal presentation (OR= 2.70 [1.23-5.93]).

CONCLUSION

The maternal morbidity of cesareans before 32 week of gestation is more than 20%. This study confirms the high maternal morbidity associated with caesareans performed before 32 weeks of gestation.

What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses

BACKGROUND

The safest delivery mode of extremely preterm breech singletons is unknown.

OBJECTIVES

To determine safest delivery mode of actively resuscitated extremely preterm breech singletons.

SEARCH STRATEGY

We searched Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov from January 1994 to May 2017.

SELECTION CRITERIA

We included studies comparing outcomes by delivery mode in actively resuscitated breech infants between 23⁺⁰ and 27⁺⁶ weeks.

DATA COLLECTION AND ANALYSIS

We synthesised data using random effects, generated odds ratios, 95% confidence intervals and number-needed-to-treat (NNT). Our primary outcomes were death (neonatal, before discharge, or by 6 months) and severe intraventricular haemorrhage (grades III/IV), stratified by gestational age (23⁺⁰ -24⁺⁶ , 25⁺⁰ -26⁺⁶ , 27⁺⁰ -27⁺⁶ weeks).

MAIN RESULTS

We included 15 studies with 12 335 infants. We found that caesarean section was associated with a 41% decrease in odds of death between 23⁺⁰ and 27⁺⁶ weeks [odds ratio (OR) 0.59, 95% CI 0.36-0.95, NNT 8], with the greatest decrease at 23⁺⁰ -24⁺⁶ weeks (OR 0.58, 95% CI 0.44-0.75, NNT 7). The OR at 25⁺⁰ -26⁺⁶ and 27⁺⁰ -27⁺⁶ weeks were 0.72 (95% CI 0.34-1.52) and 2.04 (95% CI 0.20-20.62), respectively. We found that caesarean section was associated with 49% decrease in odds of severe intraventricular haemorrhage between 23⁺⁰ and 27⁺⁶ weeks (OR 0.51, 95% CI 0.29-0.91, NNT 12), whereas the OR at 25⁺⁰ -26⁺⁶ and 27⁺⁰ -27⁺⁶ was 0.29 (95% CI 0.07-1.12) and 0.91 (95% CI 0.27-3.05), respectively.

CONCLUSIONS

Caesarean section was associated with reductions in the odds of death by 41% and of severe intraventricular haemorrhage by 49% in actively resuscitated breech singletons < 28 weeks of gestation. The data are mostly observational, which may be inherently biased, and scarce on other morbidities, necessitating thorough discussion between parents and clinicians.

TWEETABLE ABSTRACT

Caesarean section associated with lower odds of death and severe intraventricular haemorrhage in actively resuscitated breech singletons <28 weeks.

[Mode of delivery in spontaneous preterm birth]

OBJECTIVE

To evaluate the benefit/risk balance of way of birth according to fetal presentation, to assess monitoring during preterm labor, to discuss method of delivery and practice of delayed cord clamping in case of spontaneous preterm birth.

METHODS

Bibliographic research from the Pubmed database and recommendations issued by the main scientific societies, and assignment of a level of evidence and a recommendation grade.

RESULTS

In case of vertex presentation, no studies suggest that cesarean section improve neonatal outcome during spontaneous preterm birth (LE4). Nevertheless, cesarean is associated with higher maternal morbidity than vaginal delivery. Thus, routine cesarean is not recommended simply because of a spontaneous preterm labor (professional consensus). The available data do not allow specific recommendations about the choice of mode of delivery for preterm breech presentation in view of the low levels of proof (Professional consensus). Fetal rate monitoring is necessary during preterm labor (Professional consensus). Current data about second lines method for fetal surveillance (fetal scalp blood for pH or lactates) are insufficient to recommend their use before 34 WG (Professional consensus). Systematic assisted vaginal delivery is not recommended during preterm birth (Professional consensus). Use of vacuum is possible after 34 WG when cranial vertex ossification is considered satisfactory (Professional consensus). Systematic use of episiotomy in case of preterm birth is not recommended (Professional consensus). A delayed cord clamping is possible if the neonatal or maternal state so permits (Professional consensus). The available data are insufficient to recommend a systematic use of this procedure (LE3).

CONCLUSION

In case of preterm delivery, the available data do not allow specific recommendations about the choice of mode of delivery regardless of fetal presentation.

Individual and contextual determinants of adequate maternal health care services in Kenya

This study aimed to examine individual and community level factors associated with adequate use of maternal antenatal health services in Kenya. Individual and community level factors associated with adequate use of maternal health care (MHC) services were obtained from the 2008-09 Kenya Demographic and Health Survey data set. Multilevel partial-proportional odds logit models were fitted using STATA 13.0 to quantify the relations of the selected covariates to adequate MHC use, defined as a three-category ordinal variable. The sample consisted of 3,621 women who had at least one live birth in the five-year period preceding this survey. Only 18 percent of the women had adequate use of MHC services. Greater educational attainment by the woman or her partner, higher socioeconomic status, access to medical insurance coverage, and greater media exposure were the individual-level factors associated with adequate use of MHC services. Greater community ethnic diversity, higher community-level socioeconomic status, and greater community-level health facility deliveries were the contextual-level factors associated with adequate use of MHC. To improve the use of MHC services in Kenya, the government needs to design and implement programs that target underlying individual and community level factors, providing focused and sustained health education to promote the use of antenatal, delivery, and postnatal care.

Preterm birth by vacuum extraction and neonatal outcome: a population-based cohort study

BACKGROUND

Very few studies have investigated the neonatal outcomes after vacuum extraction delivery (VE) in the preterm period and the results of these studies are inconclusive. The objective of this study was to describe the use of VE for preterm delivery in Sweden and to compare rates of neonatal complications after preterm delivery by VE to those found after cesarean section during labor (CS) or unassisted vaginal delivery (VD).

METHODS

Data was obtained from Swedish national registers. In a population-based cohort from 1999 to 2010, all live-born, singleton preterm infants in a non-breech presentation at birth, born after onset of labor (either spontaneously, by induction, or by rupture of membranes) by VD, CS, or VE were included, leaving a study population of 40,764 infants. Logistic regression analyses were used to calculate adjusted odds ratios (AOR), using unassisted vaginal delivery as reference group.

RESULTS

VE was used in 5.7% of the preterm deliveries, with lower rates in earlier gestations. Overall, intracranial hemorrhage (ICH) occurred in 1.51%, extracranial hemorrhage (ECH) in 0.64%, and brachial plexus injury in 0.13% of infants. Infants delivered by VE had higher risks for ICH (AOR = 1.84 (95% CI: 1.09-3.12)), ECH (AOR = 4.48 (95% CI: 2.84-7.07)) and brachial plexus injury (AOR = 6.21 (95% CI: 2.22-17.4)), while infants delivered by CS during labor had no increased risk for these complications, as compared to VD.

CONCLUSION

While rates of neonatal complications after VE are generally low, higher odds ratios for intra- and extracranial hemorrhages and brachial plexus injuries after VE, compared with other modes of delivery, support a continued cautious use of VE for preterm delivery.

Review of the recent literature on the mode of delivery for singleton vertex preterm babies

Choosing the safest method of delivery and preventing preterm labour are obstetric challenges in reducing the number of preterm births and improving outcomes for mother and baby. Optimal route of delivery for preterm vertex neonates has been a controversial topic in the obstetric and neonatal community for decades and continues to be debated. We reviewed 22 studies, most of which have been published over the last five years with an aim to find answers to the clinical questions relevant to deciding the mode of delivery. Findings suggested that the neonatal outcome does not depend on the mode of delivery. Though Caesarean section rates are increasing for preterm births, it does not prevent neurodisability and cannot be recommended unless there are other obstetric indications to justify it. Therefore, clinical judgement of the obstetrician depending on the individual case still remains important in deciding the mode of delivery.