Neonatal Outcomes Associated with Planned Vaginal Versus Planned Primary Cesarean Delivery

EJ Geller; JM Wu; ML Jannelli; TV Nguyen; AG Visco

Disclosures

J Perinatol. 2010;30(4):258-264. 

In This Article

Abstract and Introduction

Abstract

Objective: To determine whether planned route of delivery leads to differences in neonatal morbidity.
Study design: Analysis was based on planned route of delivery, not actual route of delivery. A total of 4048 subjects were divided into two groups: planned vaginal delivery and planned cesarean delivery. Primary outcomes were neonatal intensive care unit (NICU) admission, respiratory morbidity and neurologic morbidity.
Result: There were 3868 planned vaginal and 180 planned cesarean deliveries. Planned vaginal delivery had decreased NICU admission (P<0.0001), oxygen resuscitation (P=0.001) and jaundice (P<0.0001) but increased meconium passage (P<0.0001) and 1 min Apgar ≤5 (P=0.02). After multivariable regression, NICU admission remained lower and meconium passage remained higher in the planned vaginal group.
Conclusion: Planned vaginal delivery led to more meconium passage and low 1 min Apgar but less NICU admissions, oxygen resuscitation and jaundice. Multicenter trials are needed to assess rare but serious outcomes based on planned route of delivery.

Introduction

Over the last several years, the rate of cesarean delivery has increased in the United States.[1] In 2006, the rate of cesarean delivery rose to 31.1%.[2] This is the highest rate recorded thus far and marks a 50% increase in the last decade.[2] A portion of this increase has been attributed to the declining rate of vaginal birth after cesarean. However, there has also been an increase in the rate of primary cesarean delivery to 24.3%.[3] A portion of these primary cesarean deliveries are performed on maternal request, in the absence of other medical or obstetric indication.

Cesarean delivery on maternal request (CDMR) has become a popular subject over the last several years. CDMR is defined as cesarean delivery in a singleton, term pregnancy in the absence of another maternal or fetal indication.[4] In March 2006, the National Institutes of Health convened a State-of-the-Science Conference on CDMR.[5] A comprehensive review found little evidence directly comparing outcomes between planned vaginal delivery and planned cesarean delivery. Several studies have shown a difference in neonatal outcomes for labored versus unlabored cesarean delivery.[6,7,8,9] The dilemma is predicting who among a group of women planning for a vaginal delivery will actually have a vaginal delivery. Also, many women who plan to have a vaginal delivery, especially first-time mothers, actually deliver by cesarean after labor. If only successful vaginal deliveries are compared with labored cesarean deliveries, the difference in neonatal morbidity may be misleading.[10] The NIH State-of-the-Science expert panel recommended that future research include maternal and neonatal outcomes based on planned vaginal versus planned cesarean delivery.

Our aim was to assess differences in neonatal outcomes between planned vaginal and planned cesarean delivery among births of term, low-risk primiparous women; with planned cesarean delivery being used as a proxy for CDMR. The premise of this research is aimed at understanding the effect of planned route of delivery on neonatal outcomes in an effort to understand the effect of CDMR. One critical issue is that the reported prevalence of CDMR is low in relation to the total number of primary cesarean deliveries that occur and thus does not easily lend itself to prospective analysis at this point. CDMR currently encompasses approximately 2.5% of all births in the United States.[11] Another major obstacle in evaluating CDMR is that there is no ICD-9 code for CDMR, making it very difficult to adequately document and later identify these cases for research and tracking purposes. Thus, even the estimated rate of CDMR is imprecise. On the basis of these two challenges, we have chosen to tackle the issue of CDMR in the best way that is currently available, by categorizing subjects into planned vaginal delivery or planned cesarean delivery, on the basis of NIH guidelines. Planned cesarean delivery is used as a proxy for CDMR as these women are planning to undergo a cesarean, although the reason may be breech presentation for some women and maternal desire for others. Until there are more cases of pure CDMR and a better way to identify them, we must use planned cesarean delivery as a proxy to attempt to understand the effects of planning a cesarean delivery on maternal outcomes.

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