Objective
The purpose of this study was to examine neonatal outcomes among women with a planned cesarean and a planned vaginal delivery at term.
Study design
This prospective survey was conducted on 18,653 singleton deliveries that represent 24 maternity units during a 6-month period. The data were retrieved from the Medical Birth Registry of Norway and analyzed according to intended mode of delivery.
Results
Compared with planned vaginal deliveries, planned cesarean delivery increased transfer rates to the neonatal intensive care unit from 5.2% to 9.8% [P < .001]. The risk for pulmonary disorders [transient tachypnea of the newborn infant and respiratory distress syndrome] rose from 0.8% to 1.6% [P = .01]. There were no significant differences in the risks for low Apgar score and neurologic symptoms.
Conclusion
A planned cesarean delivery doubled both the rate of transfer to the neonatal intensive care unit and the risk for pulmonary disorders, compared with a planned vaginal delivery.
Key words
- Cesarean delivery
- Mode of delivery
- Neonatal outcome
The appropriateness of the rising rate of cesarean delivery worldwide has been debated widely. Issues that relate to maternal choice,
,
mode of delivery for breech presentation at term,
and vaginal birth after previous scar
4
- Smith G.C.
- Pell J.P.
- Dobbie R.
Caesarean section and risk of unexplained stillbirth in subsequent pregnancy.
- Google Scholar
have been emphasized; and much debate has focused on subsequent maternal and neonatal morbidity.
,
,
,
,
6
- Morrison J.J.
- Rennie J.M.
- Milton P.J.
Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section.
- Crossref
- Scopus [500]
- Google Scholar
,
,
Some studies favor elective cesarean delivery because of a fear of childbirth,
9
- Schindl M.
- Birner P.
- Reingrabner M.
- Joura E.A.
- Husslein P.
- Langer M.
Elective cesarean section vs spontaneous delivery: a comparative study of birth experience.
- Crossref
- PubMed
- Scopus [82]
- Google Scholar
urinary and fecal incontinence after delivery,
breech deliveries at term,
and neonatal outcome as unexplained fetal death and complications of labor.
,
9
- Schindl M.
- Birner P.
- Reingrabner M.
- Joura E.A.
- Husslein P.
- Langer M.
Elective cesarean section vs spontaneous delivery: a comparative study of birth experience.
- Crossref
- PubMed
- Scopus [82]
- Google Scholar
,
Other surveys benefit vaginal delivery because cesarean delivery implied a higher risk of maternal death,
a longer recovery time and operative complications,
13
- Bergholt T.
- Stenderup J.K.
- Vedsted-Jakobsen A.
- Helm P.
- Lenstrup C.
Intraoperative surgical complications during cesarean section: an observational study of the incidence and risk factors.
- Crossref
- PubMed
- Scopus [104]
- Google Scholar
a higher risk of unexplained stillbirths in subsequent pregnancies,
4
- Smith G.C.
- Pell J.P.
- Dobbie R.
Caesarean section and risk of unexplained stillbirth in subsequent pregnancy.
- Google Scholar
and respiratory problems of the newborn infant.
6
- Morrison J.J.
- Rennie J.M.
- Milton P.J.
Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section.
- Crossref
- Scopus [500]
- Google Scholar
,
,
15
- Zanardo V.
- Simbi A.K.
- Franzoi M.
- Soldà G.
- Salvadori A.
- Trevisanuto D.
Neonatal respiratory morbidity risk and mode of delivery at term: influence of timing of elective caesarean delivery.
- Crossref
- PubMed
- Google Scholar
,
16
- Nicoll A.E.
- Black C.
- Powls A.
- Macenzie F.
An audit of neonatal respiratory morbidity following elective caesarean section at term.
- PubMed
- Google Scholar
In 1999, a Swedish survey concluded that an increase in the cesarean delivery rate did not reduce the perinatal mortality rate or lower the rate of asphyxia.
Morbidity and death in the neonatal period are mostly due to respiratory and cerebral disorders, particularly in preterm births. Significant respiratory morbidity after elective cesarean delivery is well known, even in term babies up to 40 weeks of gestation.
6
- Morrison J.J.
- Rennie J.M.
- Milton P.J.
Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section.
- Crossref
- Scopus [500]
- Google Scholar
,
,
15
- Zanardo V.
- Simbi A.K.
- Franzoi M.
- Soldà G.
- Salvadori A.
- Trevisanuto D.
Neonatal respiratory morbidity risk and mode of delivery at term: influence of timing of elective caesarean delivery.
- Crossref
- PubMed
- Google Scholar
,
16
- Nicoll A.E.
- Black C.
- Powls A.
- Macenzie F.
An audit of neonatal respiratory morbidity following elective caesarean section at term.
- PubMed
- Google Scholar
In 1972, the cesarean delivery rate in Norway was 2.5%. In 1987, it had risen to 12.8% and remained stable for several years. However, a slight raise has been observed in recent years; it was 15.7 % in 2002.
17
Medical Birth Registry of Norway: Annual Report 2001-2002. Bergen, Norway: University of Bergen; 2004.
- Google Scholar
There have been wide variations in cesarean delivery rates among obstetric departments in Norway [6%-20%], even when departments of comparable size and patient populations are compared.
Thus, Norway has a lower cesarean delivery rate than other countries such as the United Kingdom [22% in 2002] and the United States [25% in 2002].
,
In 1998 the Norwegian Medical Association invited maternity units in the country to participate in a “Breakthrough Project” on cesarean deliveries. Recently, 2 studies from this project have been published.
,
In the present study, we aimed to find how neonatal outcomes relate to intended mode of delivery in term pregnancies [vaginal vs cesarean delivery].
Material and methods
Data for this study were compiled from the records of 24 obstetric units that participated in the Breakthrough Project from January 1, 1999, to June 30, 1999.
Ten of these units had >2000 births per year, and 9 units had between 1000 and 2000 births in 1999.
The Breakthrough Project included only cesarean deliveries and used a comprehensive form that contained more detailed obstetric and neonatal information compared with the form used by the Medical Birth Registry of Norway [MBRN]. However, for the purposes of this study, we wanted to use the same data source for comparison of all deliveries. Therefore, all data [both from vaginal and cesarean deliveries] in the analyses were derived from the MBRN. The form used for all births in this country gives information about the medical and obstetric history, complications during pregnancy, delivery, and perinatal events. Neonatal events were prespecified. The forms were filled in before the mother and the child were discharged from the hospital, and additional information about the child was collected, if appropriate. The pediatricians at the hospitals gave the neonatal diagnoses.
This survey covered 19,288 term singleton deliveries, which according to the MBRN database represented 70.7% of all term singleton deliveries in Norway during the same period. We excluded congenital malformations [n = 546 deliveries] and cases with unspecified mode of delivery [n = 89 deliveries]. Thus, this survey included 18,653 term deliveries [Figure].
Term infants were defined as those who were delivered by a gestational age of ≥259 days, as estimated by routine ultrasound examination in the second trimester.
In this study we present the result according to 3 intended mode of delivery groups: Group 1 [planned vaginal delivery group that included all vaginal deliveries [an unselected population] and all emergency cesarean deliveries, prelabor, or in labor after a planned vaginal delivery [n = 17,828]]; group 2 [planned cesarean delivery group that included all elective cesarean deliveries [defined as all cesarean deliveries that were performed >8 hours after the decision for operation] and all emergency cesarean deliveries in those women with a planned cesarean [n = 825]]; and group 3 [subgroup of group 2: It could be argued that neonatal outcome for group 2 should be worse than in group 1 because of risk pregnancies [such as outcomes