Timing of Elective Cesarean Section and Neonatal Outcomes in Term Singleton Deliveries: A Single-Center Experience

Abstract

Objective This study aimed to evaluate the timing of elective cesarean sections at 37 to 41 weeks from a tertiary hospital in Japan. The primary outcome was the rate of adverse neonatal outcomes, especially focusing on neonates delivered at 38 weeks of gestation.

Study Design The study population was drawn from singleton pregnancies delivered following planned cesarean birth at the Fukuda Hospital from 2012 to 2019. Information on deliveries was obtained from the hospital database, which contains clinical, administrative, laboratory, and operating room databases.

Results After excluding women with chronic conditions, maternal complications, indications for multiple births, or a neonate with an anomaly, 2,208 neonates remained in the analysis. Among adverse neonatal outcomes, the rate was significantly higher in neonates delivered at 37 weeks of gestation (unadjusted odds ratio [OR] = 13.22 [95% confidence interval [CI]: 6.28, 27.86], p < 0.001) or 38 weeks of gestation (unadjusted OR = 1.82 [95% CI: 1.04, 3.19], p = 0.036) compared with neonates delivered at 39 to 41 weeks. The adjusted risk of any adverse outcome was significantly higher at 38^0–1/7 weeks (adjusted OR = 2.40 [95% CI: 1.35, 4.30], p = 0.003) and 38^2–3/7 weeks (adjusted OR = 1.89 [95% CI: 1.04, 3.44], p = 0.038) compared with neonates delivered at 39 to 41 weeks, respectively.

Conclusion Our findings suggest that elective cesarean sections might be best scheduled at 39 weeks or later. When considering a cesarean at 38 weeks, it appears that 38^4/7 weeks of gestation or later could be a preferable timing in the context of reducing neonatal risks. However, as the composite outcome includes mostly minor conditions, the clinical significance of this finding needs to be carefully interpreted.

Key Points

• Timing of elective cesarean sections from 37 to 41 weeks was evaluated in a Japanese tertiary hospital.

• Neonates delivered at 37 and 38 weeks had higher adverse outcome rates compared with 39 to 41 weeks.

• Scheduling elective cesarean sections at least 38^4/7 weeks or later may reduce neonatal risk.

Keywords

cesarean section - elective - term birth - neonatal morbidity

Authors' Contributions

D.T.: conceptualized and designed the study, designed the data collection instruments, collected the data, performed the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript. Y.F.: designed the data collection instruments, performed the initial analyses, and reviewed and revised the manuscript. T.S., A.K., S.K., and M.I.: collected the data, and reviewed and revised the manuscript. K.G.: conceptualized and designed the study and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Publikationsverlauf

Eingereicht: 25. Juli 2023

Angenommen: 21. August 2023

Accepted Manuscript online:
22. August 2023

Artikel online veröffentlicht:
19. September 2023

• References

• 1 Betrán AP, Merialdi M, Lauer JA. et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol 2007; 21 (02) 98-113
• 2 Ye J, Betrán AP, Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth 2014; 41 (03) 237-244
• 3 The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. ACOG Committee Opinion No 579: Definition of term pregnancy. Obstet Gynecol 2013; 122 (05) 1139-1140
• 4 Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011; 118 (01) 29-38
• 5 Matsuo K, Komoto Y, Kimura T, Shimoya K. Is 38 weeks late enough for elective cesarean delivery?. Int J Gynaecol Obstet 2008; 100 (01) 90-91
• 6 Tita AT, Landon MB, Spong CY. et al; Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009; 360 (02) 111-120
• 7 Glavind J, Kindberg SF, Uldbjerg N. et al. Elective caesarean section at 38 weeks versus 39 weeks: neonatal and maternal outcomes in a randomised controlled trial. BJOG 2013; 120 (09) 1123-1132
• 8 Glavind J, Henriksen TB, Kindberg SF, Uldbjerg N. Randomised trial of planned caesarean section prior to versus after 39 weeks: unscheduled deliveries and facility logistics–a secondary analysis. PLoS ONE 2013; 8 (12) e84744
• 9 Spong CY. To VBAC or not to VBAC. PLoS Med 2012; 9 (03) e1001191
• 10 Wilmink FA, Hukkelhoven CW, Lunshof S, Mol BW, van der Post JA, Papatsonis DN. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. Am J Obstet Gynecol 2010; 202 (03) 250.e1-250.e8
• 11 Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008; 336 (7635) 85-87
• 12 Doan E, Gibbons K, Tudehope D. The timing of elective caesarean deliveries and early neonatal outcomes in singleton infants born 37-41 weeks' gestation. Aust N Z J Obstet Gynaecol 2014; 54 (04) 340-347
• 13 Ertuğrul S, Gün I, Müngen E, Muhçu M, Kılıç S, Atay V. Evaluation of neonatal outcomes in elective repeat cesarean delivery at term according to weeks of gestation. J Obstet Gynaecol Res 2013; 39 (01) 105-112
• 14 Robinson CJ, Villers MS, Johnson DD, Simpson KN. Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis. Am J Obstet Gynecol 2010; 202 (06) 632.e1-632.e6
• 15 Balchin I, Whittaker JC, Lamont RF, Steer PJ. Timing of planned cesarean delivery by racial group. Obstet Gynecol 2008; 111 (03) 659-666
• 16 The American College of Obstetricians and Gynecologists. Women's Health Care Physicians. ACOG committee opinion no. 559: Cesarean delivery on maternal request. Obstet Gynecol 2013; 121 (04) 904-907
• 17 Australian R, Obstetricians NZCo, Gynaecologists. Timing of elective caesarean section. College statement C-Obs 23. Accessed April 5, 2023 at: https://ranzcog.edu.au/wp-content/uploads/2022/05/Caesarean-Birth-on-Maternal-Request-CBMR-C-Obs-39.pdf
• 18 Caesarean section 2023 . Accessed April 5, 2023 at: https://www.ncbi.nlm.nih.gov/pubmed/31944642
• 19 Kawaguchi R, Matsumoto K, Ishikawa T. et al. Guideline for Gynecological Practice in Japan: Japan Society of Obstetrics and Gynecology and Japan Association of Obstetricians and Gynecologists 2020 edition. J Obstet Gynaecol Res 2021; 47 (01) 5-25
• 20 The Terminology and Diagnostic Criteria Committee of The Japan Society of Ultrasonics in Medicine: Standardization and Japanese Standard Values of Ultrasonographic Fetal Biometry. Japanese Journal of Medical Ultrasonics 30, 415–438, 2003. (Japanese)
• 21 American College of Obstetricians and Gynecologists. Committee Opinion No 700: Methods for estimating the due date. Obstet Gynecol 2017; 129 (05) e150-e154
• 22 Minakami H, Hiramatsu Y, Koresawa M. et al; Japan Society of Obstetrics and Gynecology, Japan Association of Obstetricians and Gynecologists. Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2011 edition. J Obstet Gynaecol Res 2011; 37 (09) 1174-1197
• 23 Minakami H, Maeda T, Fujii T. et al. Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2014 edition. J Obstet Gynaecol Res 2014; 40 (06) 1469-1499
• 24 Kawaguchi R, Matsumoto K, Akira S. et al. Guidelines for office gynecology in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2017 edition. J Obstet Gynaecol Res 2019; 45 (04) 766-786
• 25 Itabashi K, Miura F, Uehara R, Nakamura Y. New Japanese neonatal anthropometric charts for gestational age at birth. Pediatr Int 2014; 56 (05) 702-708
• 26 Salim R, Shalev E. Health implications resulting from the timing of elective cesarean delivery. Reprod Biol Endocrinol 2010; 8: 68
• 27 Zanardo V, Simbi KA, Vedovato S, Trevisanuto D. The influence of timing of elective cesarean section on neonatal resuscitation risk. Pediatr Crit Care Med 2004; 5 (06) 566-570
• 28 Dueker G, Chen J, Cowling C, Haskin B. Early developmental outcomes predicted by gestational age from 35 to 41weeks. Early Hum Dev 2016; 103: 85-90
• 29 Tita ATN, Lai Y, Landon MB. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Timing of elective repeat cesarean delivery at term and maternal perioperative outcomes. Obstet Gynecol 2011; 117 (2 Pt 1): 280-286
• 30 Phaloprakarn C, Tangjitgamol S, Manusirivithaya S. Timing of elective cesarean delivery at term and its impact on maternal and neonatal outcomes among Thai and other Southeast Asian pregnant women. J Obstet Gynaecol Res 2016; 42 (08) 936-943
• 31 Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102 (02) 101-106