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

Abstract

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.

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

“…After the full manuscript was reviewed and further exclusion criteria were applied (Table S1), 37 studies [3][4][5][6][7][8][9][10][11] were considered. Of those, 27 studies (22 887 neonates) [3][4][5][6][7][8][9][10][11][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] reported quantitative data and were eventually included in the systematic review and meta-analysis.…”

“…There were no studies reporting on the primary outcome of survival to discharge. Vaginal delivery was associated with decreased odds of BPD (two studies 7,40 , n = 1078; OR 0.63 (95% CI, 0.47-0.86); I 2 = 0%, moderate quality of evidence) (Figure S7) and increased odds of NEC (three studies 6,7,40 , n = 1262; OR 1.73 (95% CI, 1.14-2.64); I 2 = 0%, moderate quality of evidence) (Figure S8). There was no significant effect of mode of delivery on the odds of IVH, RDS, CP, sepsis, neonatal composite adverse outcome, neurodevelopmental impairment or composite adverse outcome in later life.…”

“…Data on breech fetuses could be extracted from 14 studies [3][4][5]9,10,11,33,34,39,42,[44][45][46][47] , while data for cases with unspecified presentation were provided in nine studies [6][7][8]32,35,37,40,41,43 . Sixteen [3][4][5][6][7][8][9][10][11]33,40,[42][43][44][45]47 studies reported on delivery before 28 weeks and four 6,9,42,44 on delivery between 28 and 32 weeks. Fifteen 6,9,32,[34][35][36][37][38]…”

“…No studies were classified as having a low risk of bias. Twenty-one 3,4,[6][7][8][9][10][11]32,[35][36][37][39][40][41][44][45][46][47][48][49] studies were classified as having a moderate risk of bias, mainly owing to moderate risk of bias in reported results and classification of interventions. Six 5,33,34,38,42,43 studies were classified as having a serious risk of bias owing to serious risk of bias in either confounding or selection of participants.…”

“…Vaginal delivery was associated with increased odds of neonatal death (OR 1.87 (95% CI, 1.05-3.35); I 2 = 65%, very low quality of evidence), while no association with survival to discharge was observed (four studies 5,10,11,47 , n = 1355; OR 0.58 (95% CI, 0.32-1.05); I 2 = 79%, very low quality of evidence) (Table 3, Figure 2). Vaginal delivery was associated with increased odds of perinatal death (intrapartum and neonatal death) (six studies 5,7,9,33,42,44 , n = 2670; OR 2.22 (95% CI, 1.23-4.00); I 2 = 84%, low quality of evidence) (Figure S1), decreased need for mechanical ventilation (two studies 7,44 , n = 1373; OR 0.76 (95% CI, 0.59-0.99); I 2 = 0%, moderate quality of evidence) (Figure S6) and decreased odds of BPD (three studies 7,40,47 , n = 1143; OR 0.61 (95% CI, 0.45-0.83); I 2 = 0%, moderate quality of evidence) (Figure S7). There was no significant effect of mode of delivery on the risk of severe IVH, PVL, RDS, NEC, sepsis or neonatal composite adverse outcome.…”