Why a C Section at 37 Weeks for an Sga Baby

• Research article
• Open Access
• Published: 08 May 2018

'Elective caesarean section at 38–39 weeks gestation compared to > 39 weeks on neonatal outcomes: a prospective cohort study

• Motahareh Afrakhteh^three,
• Mahdi Sepidarkish⁴,
• Shahin Nariman⁵,
• Mahboobeh Shirazi^half-dozen,
• Ashraf Moini^vii,8 &
• Ladan Hosseini⁹

BMC Pregnancy and Childbirth book 18, Article number:140 (2018) Cite this article

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Abstract

Background

This study was conducted to compare neonatal complications in scheduled cesarean sections (CS) between 38 and 39 gestational weeks with CS performed after 39 gestational weeks in Iranian low -risk pregnant women.

Methods

In this cohort study, 2086 patients were enrolled based on the inclusion and exclusion criteria. The neonates were evaluated in terms of the following items: transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), sepsis, need for NICU hospitalization, birth weight, birth height, head circumference, and the outset minute and fifth infinitesimal Apgar score. Several multiple logistic regression models were performed for each response variable (agin upshot) separately.

Results

The incidence of NICU access was significantly higher in neonates built-in at 38–39 gestational weeks than those who were born after 39 gestational weeks. No significant differences were institute in the incidence of neonatal sepsis, TTN, and RDS betwixt the two groups.

Conclusion

According to our study results, elective CS at 38–9 weeks' gestation is associated with a college rate of TTN and NICU access in comparison with elective CS performed later on 39 completed gestational weeks.

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Groundwork

The appropriate gestational age for scheduled cesarean section (CS) has become a topic of interest in prenatal care [1]. For the by four decades, obstetricians and pediatricians, assuming that fetal maturity could be completed at the end of 37 gestational weeks, have divers "the term pregnancy" from that fourth dimension onwards [2]. Withal, it has now become clear that even in "the term pregnancy" (37 gestational weeks), neonatal respiratory complications will subtract with an increment in the gestational age to 39 weeks. These findings have challenged the old definition of "theterm pregnancy" [3]. Recently, the definition of "the term pregnancy" has changed to cover iii categories of premature term (37–38 weeks + 6 days), full term (39–40 weeks and half-dozen days), and late term (41-41 weeks + 6 days) [4].

Experts recommend that scheduled cesarean delivery exist conducted from 39 weeks onwards [5], so that fetal maturity is complete. Some studies have shown discrepancies in respiratory complications according to the gestational age pattern betwixt Asian and Caucasian ethnicities. The lowest complexity rate was observed in 39–40 gestational weeks in the Caucasians and in 38 gestational weeks in Asians [1]. Accordingly, this study aimed to compare neonatal complications in scheduled CS between 38 and 39 gestational weeks with scheduled CS performed after 39 gestational weeks in Iranian pregnant women.

Method and materials

This prospective cohort study was conducted at a university hospital (Arash Hospital, Tehran, Iran) from April 2013 to April 2015. All term singleton pregnancies (≥38 gestational weeks) scheduled for elective CS were enrolled in this written report. The research protocol of the study was canonical by the Ethical Inquiry Committee of Tehran University of Medical Sciences. The informed consent was obtained from all significant women. The inclusion criteria were singleton pregnancy and elective CS scheduled for 38 complete gestational weeks or later on. The exclusion criteria were gestational age below 38 completed gestational weeks, multiple pregnancy, maternal chronic diseases, gestational diabetes, preeclampsia, CS due to fetal distress, intra uterine growth restriction, meconium defecation, placenta previa or accreta, fetal abnormalities, CS during the agile stage of labor, repeated CS later beginning of uterine contracture, and any other cause of emergency CS.

All patients had two ultrasonography reports in the first trimester, one at half dozen–nine gestational weeks and the other at xi–14 gestational weeks. Gestational age was adamant based on the date of the last menstrual period (LMP). If the divergence was more than five days, gestational age was estimated based on ultrasound benchmark at 6–9 gestational weeks provided that information technology was confirmed by ultrasound at 11–14 weeks. In our practice, at least 2 ultrasound examinations are routinely performed in the starting time trimester in all pregnant women, one at 6–9 gestational weeks and the other at 11–14 gestational weeks. All ultrasound examinations were performed by a perinatologist or radiologist experienced in obstetric sonography. Gestational age (GA) was determined by measuring of the fetal crown-rump-length (CRL) at half dozen–9 and xi–14 gestational weeks. The average CRL measurement in mm was derived from three satisfactory images. CRL was converted to the equivalent number of gestational days according to Hadlock et al. (1992). All pregnant women received their antenatal care at our infirmary.

The nerveless data were maternal age, parity, neonatal weight, and neonatal complications. The following items were considered to evaluate the neonatal outcomes: transient tachypnea of the newborn (TTN) defined equally the presence of tachypnea inside hours after nativity; respiratory distress syndrome (RDS) defined as the signs of respiratory distress (radiological features and oxygen therapy), sepsis, need for NICU hospitalization, and starting time infinitesimal and 5th infinitesimal Apgar scores.

Statistical assay and sample size

The sample size was calculated on the assumption that the incidence of TTN would be three% in women with a delivery time between 38 and 39 gestational weeks and 1% in women with a delivery time ≥ 39 gestational weeks. The estimated sample size was 866 women in each grouping (α = 0.05; one - β = 0.lxxx).

Categorical and continuous variables are expressed as number (percentage) and hateful ± (standard deviation), respectively. Chi-square test was applied to compare categorical variables. Pupil'south t-test was used to compare parametric continuous variables. In order to control the potential confounders, a multiple logistic regression model was fitted for each dependent outcome variable (TTN, RDS, sepsis and demand for NICU hospitalization). Explanatory variables were considered into the model for adjustment in the following guild: maternal age, parity, neonatal weight, first minute Apgar, and fifth minute Apgar. The results are presented equally odds ratios (OR) with 95% conviction intervals. Data analysis was undertaken using the Stata statistical software, released 13.0 (Stata Corp, College Station, Tex, United states).

Results

Totally, 4892 CS were performed in our hospital during the study period, and based on the inclusion and exclusion criteria, 2086 patients were enrolled. In our study, 1002 (48%) women delivered between 38 and 39 gestational weeks and 1084 (52%) women delivered subsequently 39 gestational weeks. Indications for elective caesarean delivery were prior caesarean section in 54.five% (1137 women), breech presentation in vii.2% (150 women), suspected cephalopelvic asymmetry in 4.6% (96 women), maternal requested CS in 28.8% (601 women), and other causes such every bit retinopathy or myopathy and a history of infertility in 4.9% (102 women).

The mean ± (SD) age of the mothers who delivered between 38 to 39 gestational weeks was 27.77 ± (5.29) years, which was significantly higher than the mean (SD) age of mothers who delivered at > 39 gestational weeks (27.27 ± 5.74 years) (P = 0.041) (Tabular array i).

Tabular array 1 Comparing of demographic characteristics of participants

Total size table

Every bit shown in Table 1, repeated caesarean was more frequent in mothers who delivered between 38 and 39 gestational weeks compared to mothers who delivered after 39 gestational weeks (64.vii% vs. 45.i%, P < 0.001). Inversely, the frequency of breech presentation (x% vs. 4.2%), Cephalopelvic Disproportion (CPD) (5.4% vs. 3.8%), and maternal request (35.4% vs. 21.7%) were college in mothers who delivered later 39 weeks' gestation compared to mothers who delivered betwixt 38 and 39 gestational weeks (P < 0.001).

The weight of neonates born after 39 gestational weeks was significantly higher than neonates born between 38 and 39 gestational weeks (mean difference: 136.76, 95% CI: 103.61 to 169.91, P < 0.001). Likewise, the ane-minute Apgar score was significantly different between the 2 groups (hateful deviation: 0.02, 95% CI: 0.002 to 0.04, P = 0.029). There was no statistical significant difference in other characteristics between the ii groups .

No significant differences were found in the incidence of neonatal sepsis between the two groups (0.6 and 0.4% in neonates built-in between 38 and 39 and subsequently 39 gestational weeks respectively, adjusted OR: 1.threescore, 95% CI: 0.48 to 5.31, P = 0.440). The incidence of respiratory distress syndrome (RDS) was 0.7% (7 neonates) and 0.3% (3 neonates) in grouping one and 2, respectively. (Adjusted OR: ii.07, 95%CI: 0.56 to 7.56, P = 0.270).

The incidence of NICU admission was ii.two% (22 people) in neonates born betwixt 38 and 39 gestational weeks and 0.seven% (8 people) in those born after 39 gestational weeks. The difference was statistically significant (adjusted OR: ii.59, 95%CI: 1.xvi to 5.79, P = 0.020).

The incidence of TTN was 1.5% (xv neonates) in neonates born betwixt 38 and 39 gestational weeks (95% CI: 0.74 to two.25) and 0.5% (five people) in neonates born after 39 gestational weeks (95% CI: 0.05–0.08). The adjusted odds ratio of the association between TTN and time of delivery was 2.91 (95%CI: 1.09–7.76) (P = 0.032) using multiple logistic regression analysis, indicating that the minimal gamble of TTN in neonates born between 38 and 39 gestational weeks was nine% college compared to neonates born subsequently 39 gestational weeks. Table 2 shows rough and adjusted odds ratio of the association between adverse outcomes and time of commitment.

Table 2 Rough and adjusted odds ratio (OR) for relationship between adverse outcomes and time of delivery

Full size table

Discussion

This study showed that elective CS delivery between 38 to 39 gestational weeks is associated with a college rate of TTN and NICU admission in comparison with elective CS performed later 39 completed gestational weeks. Other major complications and more serious disorders such as respiratory distress syndrome (RDS) and sepsis were not significantly unlike betwixt the two groups.

Matsuo et al. reported severe neonatal respiratory complications (RDS and TTN) that were similar in 415 Japanese pregnant women who underwent scheduled cesarean commitment in 38 and 39 gestational weeks [six]. In a report of 442,596 Southward Asian and Black women, Balchin et al. found that the rate of respiratory dysfunction was the lowest in white infants whose mothers underwent C-section after 39 gestational weeks and in Southward Asian infants whose mothers underwent C-department at 38 gestational weeks [7]. Moreover, Trata et al. examined 1951 cases of constituent cesarean commitment in Japan and reported that constituent cesarean should be performed at 38 weeks and two days or afterward in social club to avoid respiratory complications [8].

A retrospective study of 1221 singleton pregnant women in Taiwan and Southeast Asia with scheduled cesarean commitment at 38 gestational weeks compared to 39 weeks revealed no statistically significant difference in severe neonatal complications including TTNB, RDS and NICU admission [1]. In contrast, the rate of NICU admission was higher in our study at 38 gestational weeksthan 39 gestational weeks. This difference may be attributed to differences in the hospital strategy to acknowledge infants to NICU or high frequency of TTN.

Furthermore, virtually studies on Caucasian and mainly white women take emphasized the improved neonatal outcome in scheduled cesarean deliveries at 39 gestational weeks [9, x]. Information technology has been suggested that difference in the prevalence of respiratory dysfunction at different gestational ages in white and Asian infants tin can be due to genetic differences when the fetus matures in the uterine [7, eleven]. Black and Asian infants have mostly shown meconium-stained amniotic fluid, indicating prematurity [11].

On the other hand, a multicentre clinical trial in Denmark showed that NICU admission was college in scheduled cesarean delivery at 38 gestational weeks than those built-in at 39 gestational weeks,even though the difference was non significant [5]. Information technology can be ended that race solitary cannot determine neonatal complications at dissimilar pregnancy ages. The difference of these studies conducted in the Caucasian and Asian communities in terms of the gestational age at the time of scheduled cesarean delivery can be due to differences in the sample size, failure to command confounding variables, or race.

In this study, the main reason for NICU admission was TTN, not other serious complications including RDS and sepsis. NICU admissions may lead to a large financial brunt. Christopher J. Robinson et al. reported that waiting until 39 gestational weeks to perform an constituent CS is toll effective [12]. However, the likelihood of emergency cesarean delivery and its maternal complications should too be taken into account. As suggested by some studies, the hateful gestational age in Asian and black populations is less than the whites, which tin can be due to fetal prematurity [11]. Emergency cesarean tin can be followed by complications for mothers and infants [13]. Thus, in our study, nosotros cannot draw a definite conclusion that delivery should be performed afterwards 39 gestational weeks. Further studies are required to compare the charge per unit and complications of emergency and scheduled cesarean commitment in Iranian population at 38 and 39 gestational weeks.

Ane of the concerns that causes scheduled cesarean delivery at 38 gestational weeks is prevention of unexpected fetal expiry. In this study, we did not have whatever cases of stillbirth. The chance of unexplained stillbirth at 38 gestational weeks was reported to be about 0.05 per 1000 births amid women with the history of cesarean commitment in a Scottish and a Canadian cohort written report [14, 15]. To measure out the prevalence of 0.01–ane% with sufficient accuracy and confidence, every bit many as xx,000 cases are needed [16]. Therefore, a small size of the sample may exist the reason.

In this report, the well-nigh mutual causes of cesarean delivery in the two groups were a previous history of CS and maternal request. Nonetheless, the frequency of repeated cesarean delivery was higher at 38–39 gestational weeks than its frequency after 39 gestational weeks. Two-thirds of births were done at 38–39 gestational weeks for this reason. Moreover, 56% of all repeated cesarean deliveries were performed before 39 gestational weeks. A multicentric accomplice in the United States showed that ane-third of cesarean deliveries are performed before 39 gestational weeks. The rate is between 50 and 80% in some European countries. The reason for this business organization is maternal complications in pregnancy associated with previous CS [17]. In this written report, other reasons, including maternal asking, breech presentation, and CPD, were more prevalent at 39 gestational weeks.

In our study, almost half of elective caesarean sections were performed before 39 gestational weeks. Wilmink et al. reported that more than 50% of the elective cesarean sections were done before 39 gestational weeksin the Netherlands (8.iii% at 37 gestational weeks and 48.3% at 38 gestational weeks [10]. Zanardo V. et al. reported that almost threescore% of elective cesarean sections in their hospital were performed before 38 weeks and 6 days [18] It seems that physicians, regardless of the existing documents, perform a large percentage of CS deliveries before 39 gestational weeks. It may be due to the dr.'s opinion or practice patterns, maternal request for early on CS, nascency certificate data, or any other reason.

The strong points of this report were excluding the cases of emergency cesarean delivery and a big sample size. The limitations of this study were evaluating neonatal complications only up to 28 days later birth not beyond 28 days.

Decision

Co-ordinate to our study findings, scheduled CS delivery between 38 and 39 gestational weeks is associated with a higher charge per unit of NICU access in comparing with scheduled CS performed after 39 gestational weeks. The primary reason for NICU admission was TTN, not other serious complications. Although no cases of intrauterine fetal decease occurred in women who underwent CS delivery after 39 gestational weeks, we did not accept any information on the incidence and complications of emergency CS in those who delivered after 39 weeks' gestation.Therefore, based on the results of this report, it cannot be ended that scheduled caesarean section should exist performed afterward 39 gestational weeks. Nosotros suggest that the above issue be examined in the future studies to determine the time of scheduled CS more than accurately.

Abbreviations

CPD:

Cephalopelvic Disproportion

CRL:

Fetal crown-rump-length

CS:

Cesarean sections

GA:

Gestational age

LMP:

The last menstrual flow

OR:

Odds ratios

RDS:

Respiratory distress syndrome

TTN:

Transient tachypnea of the newborn

References

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Acknowledgements

We would similar to thank the inquiry evolution center of Arash women'south infirmary for their contributions in the procedure of preparing this article.

Availability of data and materials

The datasets used and/or analyzed during the electric current written report are bachelor from the corresponding author on reasonable request.

Ethics approval and consent to participate:

Research protocol of the study was confirmed in ethical research commission of Tehran University of medical sciences. All of pregnant women sign informed consents for participating into the written report.

Writer information

Affiliations

1. Obstetrics and Gynecology Department, Arash Women's Hospital, Tehran Academy of Medical Sciences, Tehran, Iran

   Reihaneh Pirjani

2. Enquiry evolution center, Arash Women'southward Hospital, Tehran University of Medical Sciences, Tehran, Iran

   Reihaneh Pirjani

3. School of medicine, Tehran Academy of Medical Sciences, Tehran, Iran

   Motahareh Afrakhteh

4. Section of Epidemiology and Reproductive Health, Reproductive Epidemiology Enquiry Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran

   Mahdi Sepidarkish

5. Department of Pediatrics, Arash women's Hospital, Tehran University of Medical Sciences, Tehran, Iran

   Shahin Nariman

6. Maternal, Fetal and Neonatal Research Center, Tehran Academy of Medical Sciences, Tehran, Iran

   Mahboobeh Shirazi

7. Obstetrics and Gynecology Department, Arash Women'southward Hospital, Tehran Academy of Medical Sciences, Tehran, Iran

   Ashraf Moini

8. Department of Endocrinology and Female Infertility, Reproductive Biomedicine Research Center, Royan Institute for Reproductive Biomedicine, ACECR., Tehran, Iran

   Ashraf Moini

9. Research development centre, Arash Women'due south Hospital, Tehran Academy of Medical Sciences, Tehran, Iran

   Ladan Hosseini

Contributions

RP designed the study. RP,MA, SHN,AM, LH and MSH contributed in participants selection and data collection and revised the manuscript. RP and LH wrote the manuscript. MS helped in the analysis of the data. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Ladan Hosseini.

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Competing interests

The authors declare that they accept no competing interests.

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Pirjani, R., Afrakhteh, M., Sepidarkish, Grand. et al. 'Elective caesarean section at 38–39 weeks gestation compared to > 39 weeks on neonatal outcomes: a prospective accomplice study. BMC Pregnancy Childbirth 18, 140 (2018). https://doi.org/10.1186/s12884-018-1785-2

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• Received: 19 June 2017

• Accepted: 26 April 2018

• Published: 08 May 2018

• DOI : https://doi.org/10.1186/s12884-018-1785-2

Keywords

• Caesarean section
• Intensive care units
• Neonate
• Transient tachypnea of the newborn
• Respiratory distress syndrome

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