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    Elective cesarean delivery: What are we doing?

    Delivering a baby before 39 weeks with no clear medical indications may be doing more harm than good.


    Sarah J. Kilpatrick, MD, PhD
    Thirty-six percent of term repeat elective cesarean deliveries were performed at less than 39 weeks—in some centers it was as high as 52%.1 Can that possibly be true?! Not only is it true, but in this multicentered prospective study of over 24,000 repeat cesarean deliveries (CDs), there were significantly higher rates of neonatal sepsis, respiratory distress, mechanical ventilation, neonatal intensive care unit (NICU) admission, and hospitalization of over 5 days in the group delivered at less than 39 weeks. An adverse neonatal outcome occurred in 15% of those babies delivered at 37 weeks compared to 8% at 39 weeks, with NICU admission occurring in 13% at 37 weeks but only in 6% at 39 weeks. Even worse, 4% of babies at 37 weeks had respiratory distress syndrome while only 1% of babies suffered the same fate at 39 weeks. And there was no justification for these CDs, except for the fact that each mother had a prior CD. In other words there was no reason to perform them before 39 weeks. The surgery offered no benefits and in some cases it caused significant harm.

    In 1990, 10% of all pregnancies were induced but by 2006 the induction rate had more than doubled to 22.5% of all pregnancies.2 Why the increase? Have we improved neonatal or maternal outcome with this intervention? Although fetal deaths at 28 weeks or more decreased between 1990 and 2003, there has been no further change since 2003.3 Maternal mortality has not decreased since 1982.

    Certainly many of these inductions have appropriate indications and one change in practice since 1990 has been the increased use of early ultrasound, which has improved the dating of pregnancies. One benefit of improved dating is knowing when a woman becomes postterm; no doubt many of these inductions reflect the trend to induce by 41 weeks rather than wait until 42 or 43 weeks. The birthrate at greater than 40 weeks decreased coincident with this increase in inductions, suggesting that part of the increase in inductions is related to postdates inductions, a legitimate reason for an increase in inductions.2 Unfortunately, the rate of low birthweight deliveries has increased since 1990 to 8.3% in 2006, and the percentage of singleton births at 37 to 39 weeks has increased from 41% in 1990 to 55% in 2006.2 These increases are concerning in light of the increase in inductions and high percentage of elective CDs that occurred at less than 39 weeks.

    We don't know what portion of the 22% inductions is elective but generalizing from the cesarean study mentioned above it is reasonable to assume that many of them are elective. What does elective mean? It means that there is no medical indication for the delivery; that there is no reason to believe that delivery will improve either maternal or neonatal outcomes; that there is no specific fetal or maternal indication. In other words there is no benefit of the induction. Whenever any medical intervention is considered, clinicians need to weigh benefits against risks. The neonatal risks of delivery at less than 39 weeks are related to prematurity as indicated above and can be significant. What about the mother: are there maternal risks of induction? There is an increased risk of CD in nulliparous women who undergo induction particularly in those women with an unfavorable cervix. This risk seems to be limited to nulliparous women.4 There is an increased risk of hemorrhage and transfusion in women induced compared to those in spontaneous labor.4 Further there is an increase in resources used such as epidural, internal monitoring, and time in the hospital for those women who are induced.4

    Perhaps the expertise of our neonatal colleagues has given obstetricians false reassurance and lowered our threshold for induction or planned CD before 39 weeks. Neonatologists and their nurseries are excellent but, their expertise is not good enough to warrant elective delivery of women before 39 weeks. Is a 15% risk of neonatal adverse outcome that could include death worth a maternal intervention that has no benefit?

    As physicians, we should be using good judgment. The primary philosophy directing our profession is do no harm. Delivering a woman before 39 weeks with no good reason to believe that there is maternal or neonatal benefit is potentially doing harm to both mother and neonate. Share these risks with your patients. Refrain, restrain, do no harm.

    DR. KILPATRICK is Theresa S. Falcon Cullinan Professor and Head, Department of Obstetrics and Gynecology, Vice Dean, College of Medicine, University of Illinois at Chicago, Chicago, IL. She is also a member of the Contemporary OB/GYN editorial board.

    REFERENCES

    1. Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009: 360;111-120.

    2. Martin J, Hamilton B, Sutton P, et al. Births: Final Data for 2006. Natl Vital Stat Rep. 2009;57:1-102.

    3. MacDorman M, Kirmeyer S. Fetal and perinatal mortality, United States, 2005. Natl Vital Stat Rep. 2009;57:1-19.

    4. Grobman WA. Elective induction: When? Ever? Clin Obstet Gynecol. 2007:50;537-546.

    Sarah J. Kilpatrick, MD, PhD
    Dr. Kilpatrick is the Helping Hand Endowed Chair in the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los ...

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