Randomised Trial of Planned Caesarean Section Prior to Versus after 39 Weeks: Unscheduled Deliveries and Facility Logistics - A Secondary Analysis

Abstract

ObjectivesTo compare the impact of scheduling caesarean section prior to versus after 39 completed weeks of gestation on the occurrence of unscheduled caesarean section and rescheduling of the procedure. MethodsSecondary analysis from a multicentre randomised open-label trial including singleton pregnant women with a healthy foetus and a reliable due date. Women were allocated by computerized telephone randomisation to planned caesarean section at 38 weeks and three days or 39 weeks and three days. The outcomes were unscheduled deliveries with provided reasons, such as spontaneous labour onset or supervening complications, and any changes in the scheduled delivery date. Statistical analyses were according to intention-to-treat using Fisher’s exact test.ResultsFrom March 2009 to June 2011 1,274 women were included. Median difference in gestational age at delivery was six days. Compared to the 38 weeks group, the women in the 39 weeks group were more likely to have an unscheduled caesarean section (15.2% vs. 9.3%; RR 1.64, 95% CI 1.21; 2.22), to deliver between 6 pm and 8 am (10 % vs. 6%; RR 1.68, 95% CI 1.14; 2.47), or to have the procedure rescheduled (36.7% vs. 23%; RR 1.6, 95% CI 1.34;1.90). ConclusionsScheduling caesarean section after 39 weeks leads to a 60% increase in unscheduled caesarean sections and a 70% increase in delivery outside regular work hours as compared to scheduling of the procedure prior to 39 weeks. Trial Registration www.clinicaltrials.gov NCT00835003 http://www.clinicaltrials.gov/ct2/show/NCT00835003?term=NCT00835003&rank=1

Variation in and factors associated with timing of low risk, pre-labour repeat caesarean sections in NSW, 2008-2011

“…Such findings have financial and resource implications for hospitals. 19 Our findings suggest generally poor compliance with the NSW Ministry of Health policy directive concerning the timing of elective repeat caesarean sections across NSW public hospitals. Adjusted rates of compliance across NSW ranged from 32.5% to 83.7%.…”

“…18,19 For this study, despite adjustment for casemix and hospital characteristics, we found persistent, large between-hospital variation in rates of early-term repeat caesarean section, suggesting that nonmedical factors are related to the timing of low-risk, prelabour caesarean section. Patients' preferences and physicians' decision making vary, and may explain Figure 1.…”

“…Risk-adjusted hospital rates of early (37-38 weeks gestation) low-risk prelabour repeat caesarean section in NSW, 2008-2011 the remaining variation. 20 Another contributing factor may be the challenge of scheduling, which may be logistically difficult for hospitals and women 19 , particularly where travel distance to the hospital is long, such as in rural Australian communities. An Australian population cohort study found that, among low-risk women, 8.5% of caesarean sections planned for 39 weeks gestation resulted in an unscheduled caesarean section due to spontaneous labour before 39 weeks.…”

Comparison of maternal and neonatal outcome in elective lower segment cesarean section done at 38 and 39 weeks

“…4 Glavind et al, showed that 635 patients at 38 weeks and 637 patients at 39 weeks underwent elective LSCS during the study period. 13 According to Ghartey out of 2273 deliveries 51% underwent elective LSCS at 38-39 weeks.…”

“…They concluded that there is 2% increased chance of NICU admission for baby who delivered at 38 weeks. 13,25 According to Okeke et al 22.6%, babies needed NICU admission ≤38 weeks, whereas at 39 weeks only 1.8% babies needed NICU admission. 23 But according to Wilmink et al there is only 1% increase in chance of NICU admission at 38-38+6 weeks who undergo elective LSCS.…”