What we have learned about scheduling elective repeat cesarean delivery at term

Australia's persistently high rate of early-term prelabour Caesarean delivery

Objective To compare the incidence of prelabour Caesarean delivery (PCD) at early term (37 weeks and 0 days (370) to 38 weeks and 6 days (386) of gestation) between Australian states and hospital sectors over time and to compare these rates with those of England and the United States of America (USA). Method A population-based descriptive study of 556040 singleton PCDs at term (370-406 weeks) in all public and private hospitals in Australian states, 2005-16, was performed. The primary outcome was the early-term PCD rate, defined as early-term PCDs as a percentage of all term PCDs. Results Across Australian states, the early-term PCD rate fell from 56.4% in 2005 to 52.0% in 2016. Over a similar period, England's rate fell from 48.2% in 2006-07 to 35.2% in 2016-17, while the USA's rate fell from 47.4% in 2006 to 34.2% in 2016. Australian public hospitals reduced their rate from 54.2% in 2005 to 44.7% in 2016, but the rate increased in private hospitals from 59.1% in 2005 to 62.5% in 2016. There was considerable variation between states and hospital sectors. Conclusions The early-term PCD rate increased in Australian private hospitals from 2005 to 2016. The public hospital rate fell by nearly 10% over the period but remained ~10% above the English and USA national rates. What is known about the topic? Babies born at early term (370-386 weeks) are at greater risk of morbidity than babies born at full term (390-406 weeks). Australia has a persistently high rate of early-term prelabour Caesarean delivery (PCD). What does this paper add? This paper reveals concerning differences in the early-term PCD rate between Australian states and hospital sectors. Further, the paper highlights that both Australian hospital sectors (public and private) have not reduced their rates to levels achieved in England and the USA. What are the implications for practitioners? These results should inform efforts to reduce Australia's early-term PCD rate to prevent harm to babies.

ACOG Committee Opinion No. 765: Avoidance of Nonmedically Indicated Early-Term Deliveries and Associated Neonatal Morbidities

There are medical indications in pregnancy for which there is evidence or expert opinion to support delivery versus expectant management in the early-term period. However, the risk of adverse outcomes is greater for neonates delivered in the early-term period compared with neonates delivered at 39 weeks of gestation. In addition to immediate adverse perinatal outcomes, multiple studies have shown increased rates of adverse long-term infant outcomes associated with late-preterm and early-term delivery compared with full-term delivery. A recent systematic review found that late-preterm and early-term children have lower performance scores across a range of cognitive and educational measures compared with their full-term peers. Further research is needed to better understand if these differences are primarily based on gestational age at delivery versus medical indications for early delivery. Documentation of fetal pulmonary maturity alone does not necessarily indicate that other fetal physiologic processes are adequately developed. For this reason, amniocentesis for fetal lung maturity is not recommended to guide timing of delivery, even in suboptimally dated pregnancies. Avoidance of nonmedically indicated delivery before 39 0/7 weeks of gestation is distinct from, and should not result in, an increase in expectant management of patients with medical indications for delivery before 39 0/7 weeks of gestation. Management decisions, therefore, should balance the risks of pregnancy prolongation with the neonatal and infant risks associated with early-term delivery. Although there are specific indications for delivery before 39 weeks of gestation, a nonmedically indicated early-term delivery should be avoided. This document is being revised to reflect updated data on nonmedically indicated early-term deliveries.

Birth mode and infectious morbidity risks in Qom children of Argentina

OBJECTIVES

Cesarean delivery may increase childhood infectious morbidity risks via altered birth exposures and subsequent immune, microbial, and epigenetic development. Many Latin American indigenous populations experience dual burdens of infectious and chronic diseases, and are particularly vulnerable to rising rates of cesarean delivery and associated adverse outcomes. The Qom/Toba are an indigenous population in Argentina experiencing rapid lifestyle transitions. We hypothesized that cesarean delivery would be associated with increased risk of infectious symptoms in Qom children after adjusting for gestational and nutritional factors.

METHODS

We conducted a secondary analysis of birth records and monthly anthropometric and illness data collected previously from 90 Qom children (aged 1-55 months). We tested for additive effects of birth mode on risk of gastrointestinal (GI) and respiratory illness (RI) in mixed-effects logistic regression models adjusting for child weight-for-age (WAZ), weaning, and gestational and maternal age.

RESULTS

Cesarean deliveries accounted for 46% of births and were associated with maternal age < 20 and ≥ 30 years, gestational age < 39 weeks, and prenatal complications. GI and RI risks were reduced in association with cesarean delivery, greater WAZ, weaning, maternal age ≥ 30 years, and gestational age < 39 weeks.

CONCLUSIONS

The relationship between cesarean delivery and reduced infectious risks may reflect statistical confounding with relatively rapid postnatal growth and greater adiposity. Postnatal growth trajectories may be important mediators of long-term morbidity risks associated with cesarean delivery. The frequency of cesarean deliveries among the Qom remains concerning given traditionally high rates of fertility and adolescent pregnancy.

National Quality Measures in Perinatal Medicine

There are numerous measures of perinatal quality endorsed by national agencies such as the National Quality Forum (NQF). The sheer number of metrics may lead to confusion about what these measures truly assess, and how to interpret variation in these measures across hospitals, health care systems, and geographic regions. This review presents a conceptual model for the numerous validated measures, an overview of the types of measures endorsed for perinatal quality by NQF in 2016, and potential measures absent from endorsement by these national bodies.

Optimal timing for elective caesarean delivery in a Chinese population: a large hospital-based retrospective cohort study in Shanghai

OBJECTIVE

To assess the relationship between the timing of antepartum elective caesarean delivery (CD) at term and perinatal outcomes in a Chinese population.

METHODS

We conducted a retrospective cohort study of mode of delivery at a large obstetric centre in Shanghai, China between 2007 and 2014. Eligibility criteria included: term nulliparous women with a singleton gestation undergoing antepartum elective CD.

RESULTS

There were 19 939 women delivered by antepartum CD without indications, with 5.9% performed at 37-37 6/7 weeks, 36.2% at 38-38 6/7 weeks, 38.4% at 39-39 6/7 weeks, 15.4% at 40-40 6/7 weeks, 4.0% at ≥41 weeks. As compared with births at 39-39 6/7 weeks, births at 37 weeks were associated with an increased odds of neonatal respiratory disease (adjusted odds ratian(aOR): 4.82; 95% CI 3.35 to 6.94), neonatal infection (aOR: 3.68; 95% CI 1.80 to 7.52), hypoglycaemia (aOR: 3.85; 95%CI 2.29 to 6.48), hyperbilirubinaemia (aOR: 3.50; 95%CI 2.12 to 5.68), neonatal intensive care admission (aOR: 3.73; 95% CI 2.84 to 4.89) and prolonged hospitalisation (aOR: 7.51; 95% CI 5.10 to 11.07). Births at 38 weeks, 40 weeks or ≥41 weeks were also associated with an increased odds of neonatal respiratory disease with corresponding aORs (95% CI) of 2.26 (1.71 to 3.00), 1.97 (1.33 to 2.94) and 2.91 (1.80 to 4.70), respectively.

CONCLUSION

For women undergoing elective CD, neonatal outcome data suggest that delivery at 39-39 6/7 complete weeks is optimal timing in a Chinese population.