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      Elective Cesarean Section on Term Pregnancies Has a High Risk for Neonatal Respiratory Morbidity in Developed Countries: A Systematic Review and Meta-Analysis

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          Abstract

          Background: Cesarean section (CS) is one of the most recurrently carried out surgical procedures in modern obstetrics. Worldwide, about 18.5 million CSs are conducted annually. Of this, 21–33% are performed in middle-and high-income countries. The effectiveness of the CS in preventing maternal and prenatal mortality and morbidity is medically justifiable. However, cesarean delivery without demanding obstetrical indications, by mere maternal request, may expose the child to several risks over benefits. Therefore, we aim to compare spontaneous vaginal delivery (vaginal delivery other than operative vaginal deliveries) and elective CS (CS before the onset of labor, but not including emergency CS) in decreasing the risk of neonatal respiratory morbidity.

          Objective: To compare the risk of neonatal respiratory morbidity in ECS and spontaneous vaginal delivery.

          Methods: A literature search was performed through visiting an electronic database (MEDLINE, PubMed, EMBASE, and CINAHL) and gray literature sources, including Google and Google Scholar, from January 2000 to May 2018. Original observational studies that reported the risk of neonatal respiratory morbidity in relation to mode of delivery conducted in the English language were identified and screened. Joanna Briggs Institute's quality assessment tool for observational studies was used to critically appraise the methodological quality of studies. Synthesis of individual studies was conducted using the Review Manager Software version 5.3 for Windows. Heterogeneity among studies was explored using the Cochran's Q-test and the I 2 statistics. Pooled effect sizes in relative risk ratios with 95% confidence intervals were calculated. The flow of the study was prepared according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist.

          Results: Sixteen studies were reviewed. A total of 327,272 neonates born by vaginal delivery and 55,246 born by ECS were included in this study. The risk of neonatal respiratory morbidity was increased by 95% in neonates delivered by ECS ( RR = 1.95; 95% CI: 1.40–2.73) as compared with neonates born by spontaneous vaginal delivery.

          Conclusion: This study investigated the effect of mode of delivery on the respiratory morbidity without considering other risks and found that the ECS has a high risk of developing neonatal respiratory morbidities when compared to spontaneous vaginal delivery. So, we recommend discouraging unnecessary CS.

          registration: CRD42018104905.

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

          Niels Uldbjerg, Kirsten Wisborg, Immo Hansen … (2008)
          To investigate the association between elective caesarean sections and neonatal respiratory morbidity and the importance of timing of elective caesarean sections. Cohort study with prospectively collected data from the Aarhus birth cohort, Denmark. Obstetric department and neonatal department of a university hospital in Denmark. All liveborn babies without malformations, with gestational ages between 37 and 41 weeks, and delivered between 1 January 1998 and 31 December 2006 (34 458 babies). Respiratory morbidity (transitory tachypnoea of the newborn, respiratory distress syndrome, persistent pulmonary hypertension of the newborn) and serious respiratory morbidity (oxygen therapy for more than two days, nasal continuous positive airway pressure, or need for mechanical ventilation). 2687 infants were delivered by elective caesarean section. Compared with newborns intended for vaginal delivery, an increased risk of respiratory morbidity was found for infants delivered by elective caesarean section at 37 weeks' gestation (odds ratio 3.9, 95% confidence interval 2.4 to 6.5), 38 weeks' gestation (3.0, 2.1 to 4.3), and 39 weeks' gestation (1.9, 1.2 to 3.0). The increased risks of serious respiratory morbidity showed the same pattern but with higher odds ratios: a fivefold increase was found at 37 weeks (5.0, 1.6 to16.0). These results remained essentially unchanged after exclusion of pregnancies complicated by diabetes, pre-eclampsia, and intrauterine growth retardation, or by breech presentation. Compared with newborns delivered vaginally or by emergency caesarean sections, those delivered by elective caesarean section around term have an increased risk of overall and serious respiratory morbidity. The relative risk increased with decreasing gestational age.
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            Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section.

            Liam J. Morrison, Mark Milton, Katherine J. Rennie (1995)
            To establish whether the timing of delivery between 37 and 42 weeks gestation influences neonatal respiratory outcome and thus provide information which can be used to aid planning of elective delivery at term. All cases of respiratory distress syndrome or transient tachypnoea at term requiring admission to the neonatal intensive care unit were recorded prospectively for nine years. Rosie Maternity Hospital, Cambridge. During this time 33,289 deliveries occurred at or after 37 weeks of gestation. This information enabled calculation of the relative risk of respiratory morbidity for respiratory distress syndrome or transient tachypnoea in relation to mode of delivery and onset of parturition for each week of gestation at term. The incidence of respiratory distress syndrome at term was 2.2/1000 deliveries (95% CI; 1.7-2.7). The incidence of transient tachypnoea was 5.7/1000 deliveries (95% CI; 4.9-6.5). The incidence of respiratory morbidity was significantly higher for the group delivered by caesarean section before the onset of labour (35.5/1000) compared with caesarean section during labour (12.2/1000) (odds ratio, 2.9; 95% CI 1.9-4.4; P < 0.001), and compared with vaginal delivery (5.3/1000) (odds ratio, 6.8; 95% CI 5.2-8.9; P < 0.001). The relative risk of neonatal respiratory morbidity for delivery by caesarean section before the onset of labour during the week 37+0 to 37+6 compared with the week 38+0 to 38+6 was 1.74 (95% CI 1.1-2.8; P < 0.02) and during the week 38+0 to 38+6 compared with the week 39+0 to 39+6 was 2.4 (95% CI 1.2-4.8; P < 0.02). A significant reduction in neonatal respiratory morbidity would be obtained if elective caesarean section was performed in the week 39+0 to 39+6 of pregnancy.
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              Neonatal respiratory morbidity risk and mode of delivery at term: influence of timing of elective caesarean delivery.

              A Salvadori, V Zanardo, M. Franzoi … (2004)
              To establish whether the timing of delivery between 37 + 0 and 41 + 6 wk gestation influences neonatal respiratory outcome in elective caesarean delivery, following uncomplicated pregnancy, thus providing information that can be used to aid planning of elective delivery at term. All pregnant women who were delivered by elective caesarean delivery at term during a 3-y period were identified from a perinatal database and compared retrospectively with pregnant women matched for week of gestation, who were vaginally delivered. Maternal characteristics, neonatal outcome, incidence of respiratory distress syndrome (RDS) and transient tachypnea of the newborn (TTN) were analysed. During this time, 1284 elective caesarean section deliveries occurred at or after 37 + 0 wk of gestation. Neonatal respiratory morbidity risk (odds ratio, OR), including RDS and TTN, was significantly higher in the infant group delivered by elective caesarean delivery compared with vaginal delivery (OR 2.6; 95% CI: 1.35-5.9; p 0.05), the RDS risk was significantly increased (OR 5.85; 95% CI: 2.27-32.4; p < 0.01). This RDS risk is greatly increased in weeks 37 + 0 to 38 + 6 (OR 12.9; 95% CI: 3.57-35.53; p < 0.01). After 39 + 0 wk, there was no significant difference in RDS risk. Infants born by elective caesarean delivery at term are at increased risk for developing respiratory disorders compared with those born by vaginal delivery. A significant reduction in neonatal RDS would be obtained if elective caesarean delivery were performed after 39 + 0 gestational weeks of pregnancy.
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                Author and article information

                Contributors
                Journal
                Journal ID (nlm-ta): Front Pediatr
                Journal ID (iso-abbrev): Front Pediatr
                Journal ID (publisher-id): Front. Pediatr.
                Title: Frontiers in Pediatrics
                Publisher: Frontiers Media S.A.
                ISSN (Electronic): 2296-2360
                Publication date (Electronic): 25 June 2020
                Publication date Collection: 2020
                Volume: 8
                Electronic Location Identifier: 286
                Affiliations
                [1] 1School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University , Harar, Ethiopia
                [2] 2Department of Environmental Health Sciences, College of Health and Medical Sciences, Haramaya University , Harar, Ethiopia
                Author notes

                Edited by: Frederick Robert Carrick, University of Central Florida College of Medicine, United States

                Reviewed by: Jon Hyett, Royal Prince Alfred Hospital, Australia; Ibrahim A. Abdelazim, Ain Shams University, Egypt

                *Correspondence: Teshager Worku teshager.kassie@ 123456gmail.com

                This article was submitted to Children and Health, a section of the journal Frontiers in Pediatrics

                Article
                DOI: 10.3389/fped.2020.00286
                PMC ID: 7330011
                PubMed ID: 32670995
                SO-VID: 82383213-95fa-4615-a2c4-1e085028f7a1
                Copyright © Copyright © 2020 Tefera, Assefa, Mengistie, Abrham, Teji and Worku.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                Date received : 25 October 2019
                Date accepted : 06 May 2020
                Page count
                Figures: 7, Tables: 2, Equations: 0, References: 31, Pages: 12, Words: 5965
                Categories
                Subject: Pediatrics
                Subject: Systematic Review

                Keywords: respiratory morbidity,newborn,elective cesarean section,spontaneous vaginal delivery,term pregnancies
                Data availability:
                Keywords: respiratory morbidity, newborn, elective cesarean section, spontaneous vaginal delivery, term pregnancies

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