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Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39405.539282.BE (Published 10 January 2008) Cite this as: BMJ 2008;336:85

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Further evidence of reduced infant morbidity with cesarean delivery on maternal request at 39 weeks EGA

Sir,

As a journalist and writer with a special interest in caesarean
delivery and a woman whose own birth choice was cesarean delivery on
maternal request (CDMR) with no medical indication (up until the eighth
month of my pregnancy when breech presentation was discovered), I would
like to make five observations on this very useful study by Hansen et al
with the aim of informing future research and analysis in this area.

1) Hansen et al extract: “For our final analyses we categorised
deliveries into two groups: elective caesarean section and intended
vaginal delivery - that is, all vaginal deliveries and emergency caesarean
sections.”

Comment: It is very refreshing to see research that includes emergency
cesarean outcomes in its analysis of an ‘intended vaginal delivery’ group.

To date, most research analysis either ignores this link or compares all
cesarean outcomes (emergency and elective combined) with successful
planned vaginal delivery (PVD) outcomes alone. Going forward, the
inclusion of emergency caesarean outcomes in PVD risk analysis (in at
least one component of the research) - when comparing PVD and planned
elective cesarean delivery mortality and morbidity (for mothers and
infants) - will aid the emergence of a much clearer picture of the risks
and benefits of each. Hansen et al caution: “Exclusion of emergency
caesarean sections from the comparison group could have resulted in an
overestimation of the effect of elective caesarean section…,” and this is
precisely what future studies need to acknowledge in order to ensure the
most accurate and relevant conclusions.

2) Extract: “Our results also suggest that a significant reduction
in neonatal respiratory morbidity may be obtained if elective caesarean
section is postponed to 39 weeks’ gestation. This information should be
taken into consideration by women contemplating an elective caesarean
section and by the obstetricians counselling them.”

Comment: Hansen et al reiterate the widely established advice for elective
caesarean deliveries, which is to wait until 39 weeks estimated
gestational age (EGA). (1-7)

3) Extract [on the increased risk of respiratory morbidity]: “the
risk was doubled in infants delivered at 39 weeks’ gestation (1.9, 1.2 to
3.0; table 2).”

Comment: Assuming that women and their obstetricians heed the advice given
above (waiting until 39 weeks EGA), women choosing elective caesarean
delivery need to look at the corresponding data presented by Hansen et al.
Of 1074 babies, 23 (2.1%) had respiratory morbidity following elective
caesarean delivery compared with 89 of 7755 (1.1%) following PVD. This
doubled risk should undoubtedly be taken into consideration by pregnant
women - but in the context of other risks for the infant with PVD that
have been recognized in other studies. All of the following outcomes for
infants have been found to have a greater risk with PVD (and in
particular, with forceps and ventouse assisted PVD): significant fetal
injury and demise, (8) neonatal complications, (9) neonatal intracranial
hemorrhage, (10) cephalhematoma and intracranial hemorrhage, (11) caput,
jaundice and cephalohematoma, (12) cranial traumatic injury (13) shoulder
dystocia, (14-16) shoulder dystocia and cephalohematoma, (16) and
sequential PVD assistance results in even higher morbidity. (18,19) Both
ACOG (20) and the NIH (3) have acknowledged a substantial number of
increased benefits for the infant with elective caesarean delivery at 39
weeks EGA.

4) Extract [on the increased risk of serious respiratory morbidity]:
“…the relative risk at 39 weeks was no longer statistically significant.”

Comment: Again, assuming that women and their obstetricians heed the
advice given above (waiting until 39 weeks EGA), women choosing elective
caesarean delivery need to look at the corresponding data presented by
Hansen et al. The percentage risk of serious respiratory morbidity was
0.1% for PVD and 0.2% for elective caesarean.

5) Extract: “…788 women had a caesarean section by patient choice.
Repeated analyses of these showed risk estimates similar to those
calculated for our low risk population.”

Comment: Related to the point made in comment 1 above (the need for
analysis of birth outcome in direct relation to the birth plan intended),
Hansen et al demonstrate a low risk for CDMR in their study. Given the
current controversy surrounding CDMR in some countries, this is an area of
research that requires further attention, especially since it is
established that many risks associated with CDMR are lower than other
types of caesarean delivery. (3)

In conclusion: Contrary to some media interpretation and commentary
following the publication of Hansen et al’s study, the actual risks
relevant to CDMR at 39 weeks EGA (above) should conceivably dilute
concerns that women are endangering the health of their child by choosing
caesarean delivery or that caesarean delivery is an unreasonable request
with regard to the infant’s wellbeing.

References

(1) Maternity - Timing of Elective or Pre-Labour Caesarean Section,
PD2007_024. 03-Apr-2007. Primary Health and Community Partnerships, New
South Wales. File No. 04/3435-5
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_024.pdf

(2) Planned cesarean versus planned vaginal delivery at term:
comparison of newborn infant outcomes. Kolas T, Saugstad OD, Daltveit AK,
Nilsen ST, Oian P. Am J Obstet Gynecol. 2006 Dec;195(6):1538-43. Epub 2006
Jul 17. PMID: 16846577. Department of Obstetrics and Gynecology, Innlandet
Hospital Trust, Lillehammer, Norway.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&lis...

(3) National Institutes of Health State-of-the-Science Conference
Statement Cesarean Delivery on Maternal Request, March 27-29, 2006
(Published 15 Jun 06)
http://consensus.nih.gov/2006/CesareanStatement_Final053106.pdf

(4) An audit of neonatal respiratory morbidity following elective
caesarean section at term. Nicoll AE, Black C, Powls A, Mackenzie F. Scott
Med J. 2004 Feb;49(1):22-5. PMID: 15012048. Princess Royal Maternity
Hospital, 16 Alexandra Parade, Glasgow.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(5) The influence of timing of elective cesarean section on neonatal
resuscitation risk. Zanardo V, Simbi KA, Vedovato S, Trevisanuto D.
Pediatr Crit Care Med. 2004 Nov;5(6):566-70. PMID: 15530194. Department of
Pediatrics, Padua University School of Medicine, Via Giustiniani 3, 35128
Padua, Italy.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&lis...

(6) Neonatal respiratory morbidity risk and mode of delivery at term:
influence of timing of elective caesarean delivery. Zanardo V, Simbi AK,
Franzoi M, Solda G, Salvadori A, Trevisanuto D. Acta Paediatr. 2004
May;93(5):643-7. PMID: 15174788. Department of Paediatrics, Padua
University School of Medicine, Padua, Italy.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(7) Neonatal respiratory morbidity and mode of delivery at term:
influence of timing of elective caesarean section. Morrison JJ, Rennie JM,
Milton PJ. Br J Obstet Gynaecol. 1995 Feb;102(2):101-6. PMID: 7756199.
Department of Obstetrics and Gynaecology, University College London
Medical School, UK.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&lis...

(8) Cesarean section on request at 39 weeks: impact on shoulder
dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal
demise. Hankins GD, Clark SM, Munn MB. Semin Perinatol. 2006 Oct;30(5):276
-87. PMID: 17011400. The University of Texas Medical Branch, Department of
Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Galveston,
TX 77555-0587, USA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(9) Short-term maternal and neonatal outcomes by mode of delivery A
case-controlled study. Chiara Benedettoa, Luca Marozioa, Giovanna Prandib,
Ajit Rocciaa, Silvia Blefaria and Claudio Fabrisb aDepartment of
Obstetrics and Gynecology, University of Torino, Italy. bNeonatal Care
Unit, Department of Paediatrics, University of Torino, Italy. Received 9
February 2006; revised 10 October 2006; accepted 20 October 2006.
Available online 28 November 2006. European Journal of Obstetrics &
Gynecology and Reproductive Biology Volume 135, Issue 1, November 2007,
Pages 35-40 doi:10.1016/j.ejogrb.2006.10.024
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T69-4MFJJGG-
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info(%23toc%235025%232007%23998649998%23673016%23FLA%23display%23Volume)&_cdi=5025&_sort=d&_docanchor=&_ct=31&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=02a7fe5fbca83882cde0163bd95874d9

(10) Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on
MR Images and Relationship to Obstetric and Neonatal Risk Factors.
Christopher B. Looney, BS, J. Keith Smith, MD, PhD, Lisa H. Merck, MD,
MPH, Honor M. Wolfe, MD, Nancy C. Chescheir, MD, Robert M. Hamer, PhD and
John H. Gilmore, MD Radiology 2007;242:535-541
http://radiology.rsnajnls.org/cgi/content/abstract/242/2/535

(11) Comparison of maternal and infant outcomes between vacuum
extraction and forceps deliveries. Wen SW, Liu S, Kramer MS, Marcoux S,
Ohlsson A, Sauve R, Liston R. Am J Epidemiol. 2001 Jan 15;153(2):103-7.
PMID: 11159152. Bureau of Reproductive and Child Health, Centre For
Healthy Human Development, Health Canada, Ottawa, Ontario.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(12) Forceps or vacuum extraction: a comparison of maternal and
neonatal morbidity.
Shihadeh A, Al-Najdawi W. East Mediterr Health J. 2001 Jan-Mar;7(1-2):106-
14. PMID: 12596959. Department of Obstetrics and Gynaecology, Royal
Medical Services, Amman, Jordan.
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(13) Review of singleton fetal and neonatal deaths associated with
cranial trauma and cephalic delivery during a national intrapartum-related
confidential enquiry. O'Mahony F, Settatree R, Platt C, Johanson R. BJOG.
2005 May;112(5):619-26. PMID: 15842287. Clinical Governance Office, Ward
59, North Staffordshire Maternity Unit, Stoke on Trent ST4 6QG, UK.
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(14) Shoulder dystocia and brachial plexus injury: a case-control
study. Christoffersson M, Kannisto P, Rydhstroem H, Stale H, Walles B.
Acta Obstet Gynecol Scand. 2003 Feb;82(2):147-51. PMID: 12648177.
Department of Obstetrics and Gynecology at Central Hospital, Kalmar,
Sweden.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(15) Shoulder dystocia and brachial plexus injury: a case-control
study. Christoffersson M, Kannisto P, Rydhstroem H, Stale H, Walles B.
Acta Obstet Gynecol Scand. 2003 Feb;82(2):147-51. PMID: 12648177.
Department of Obstetrics and Gynecology at Central Hospital, Kalmar,
Sweden.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(16) Management of Shoulder Dystocia Trends in Incidence and Maternal
and Neonatal Morbidity I. Z. MacKenzie, FRCOG1, Mutayyab Shah, MRCOG1,
Katie Lean, RM1, Susan Dutton, MSc1, Helen Newdick, BEd1 and Danny E.
Tucker, MRCOG1 From the Nuffield Department of Obstetrics and Gynaecology,
University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.1
Obstetrics & Gynecology 2007;110:1059-1068 © 2007 by The American
College of Obstetricians and Gynecologists
http://www.greenjournal.org/cgi/content/abstract/110/5/1059

(17) Forceps compared with vacuum: rates of neonatal and maternal
morbidity. Caughey AB, Sandberg PL, Zlatnik MG, Thiet MP, Parer JT, Laros
RK Jr. Obstet Gynecol. 2005 Nov;106(5 Pt 1):908-12. PMID: 16260505.
Department of Obstetrics, Gynecology and Reproductive Sciences, University
of California-San Francisco, 505 Parnassus Avenue, Box 132, San Francisco,
CA 94143, USA.
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(18) What to do after a failed attempt of vacuum delivery? Sadan O,
Ginath S, Gomel A, Abramov D, Rotmensch S, Boaz M, Glezerman M. Eur J
Obstet Gynecol Reprod Biol. 2003 Apr 25;107(2):151-5. PMID: 12648860.
Department of Obstetrics and Gynecology, Sackler Faculty of Medicine,
Edith Wolfson Medical Center, Tel-Aviv University, Tel-Aviv, Israel.
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(19) Failed individual and sequential instrumental vaginal delivery:
contributing risk factors and maternal-neonatal complications. Al-Kadri H,
Sabr Y, Al-Saif S, Abulaimoun B, Ba'Aqeel H, Saleh A. Acta Obstet Gynecol
Scand. 2003 Jul;82(7):642-8. PMID: 12790846. Department of Obstetrics and
Gynecology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubm...

(20) ACOG Committee Opinion No. 394: Cesarean Delivery on Maternal
Request. Obstet. Gynecol., December 1, 2007; 110(6): 1501. PMID: 18055756
http://highwire.stanford.edu/cgi/medline/pmid;18055756

Competing interests:
Pauline McDonagh Hull is editor of a website providing information on elective caesarean delivery, and it is her personal belief that CDMR (or EPCD (elective prophylactic caesarean delivery) as it is also referred to) is a legitimate birth choice for healthy women.

Competing interests: No competing interests

03 March 2008
Pauline M Hull
Writer and journalist
Hellertown, PA 18055 USA