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Review
, 2013 (9), CD000078

Caesarean Section Versus Vaginal Delivery for Preterm Birth in Singletons

Affiliations
Review

Caesarean Section Versus Vaginal Delivery for Preterm Birth in Singletons

Zarko Alfirevic et al. Cochrane Database Syst Rev.

Abstract

Background: Planned caesarean delivery for women thought be in preterm labour may be protective for baby, but could also be quite traumatic for both mother and baby. The optimal mode of delivery of preterm babies for both cephalic and breech presentation remains, therefore, controversial.

Objectives: To assess the effects of a policy of planned immediate caesarean delivery versus planned vaginal birth for women in preterm labour.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (5 August 2013).

Selection criteria: Randomised trials comparing a policy of planned immediate caesarean delivery versus planned vaginal delivery for preterm birth.

Data collection and analysis: Two review authors independently assessed trials for inclusion. Two review authors independently extracted data and assessed risk of bias. Data were checked for accuracy.

Main results: We included six studies (involving 122 women) but only four studies (involving only 116 women) contributed data to the analyses. INFANT: There were very little data of relevance to the three main (primary) outcomes considered in this review: There was no significant difference between planned immediate caesarean section and planned vaginal delivery with respect to birth injury to infant (risk ratio (RR) 0.56, 95%, confidence interval (CI) 0.05 to 5.62; one trial, 38 women) or birth asphyxia (RR 1.63, 95% CI 0.84 to 3.14; one trial, 12 women). The only cases of birth trauma were a laceration of the buttock in a baby who was delivered by caesarean section and mild bruising in another allocated to the group delivered vaginally.The difference between the two groups with regard to perinatal deaths was not significant (0.29, 95% CI 0.07 to 1.14; three trials, 89 women) and there were no data specifically relating to neonatal admission to special care and/or intensive care unit.There was also no difference between the caesarean or vaginal delivery groups in terms of markers of possible birth asphyxia (RR 1.63, 95% CI 0.84 to 3.14; one trial, 12 women) or Apgar score less than seven at five minutes (RR 0.83, 95% CI 0.43 to 1.60; four trials, 115 women) and no difference in attempts at breastfeeding (RR 1.40, 95% 0.11 to 17.45; one trial, 12 women). There was also no difference in neonatal fitting/seizures (RR 0.22, 95% CI 0.01 to 4.32; three trials, 77 women), hypoxic ischaemic encephalopathy (RR 4.00, 95% CI 0.20 to 82.01;one trial, 12 women) or respiratory distress syndrome (RR 0.55, 95% CI 0.27 to 1.10; three trials, 103 women). There were no data reported in the trials specifically relating to meconium aspiration. There was also no significant difference between the two groups for abnormal follow-up in childhood (RR 0.65, 95% CI 0.19 to 2.22; one trial, 38 women) or delivery less than seven days after entry (RR 0.95, 95% CI 0.73 to 1.24; two trials, 51 women). MOTHER: There were no data reported on maternal admissions to intensive care. However, there were seven cases of major maternal postpartum complications in the group allocated to planned immediate caesarean section and none in the group randomised to vaginal delivery (RR 7.21, 95% CI 1.37 to 38.08; four trials, 116 women).There were no data reported in the trials specifically relating to maternal satisfaction (postnatal). There was no significant difference between the two groups with regard to postpartum haemorrhage. A number of non-prespecified secondary outcomes were also considered in the analyses. There was a significant advantage for women in the vaginal delivery group with respect to maternal puerperal pyrexia (RR 2.98, 95% CI 1.18 to 7.53; three trials, 89 women) and other maternal infection (RR 2.63, 95% CI 1.02 to 6.78; three trials, 103 women), but no significant differences in wound infection (RR 1.16, 95% CI 0.18 to 7.70; three trials, 103 women), maternal stay more than 10 days (RR 1.27, 95% CI 0.35 to 4.65; three trials, 78 women) or the need for blood transfusion (results not estimable).

Authors' conclusions: There is not enough evidence to evaluate the use of a policy of planned immediate caesarean delivery for preterm babies. Further studies are needed in this area, but recruitment is proving difficult.

Conflict of interest statement

None known.

Figures

1
1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 1 Birth injury to infant.
1.2
1.2. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 2 Birth asphyxia.
1.3
1.3. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 3 Perinatal death.
1.5
1.5. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 5 Hypoxic ischemic encephalopathy.
1.6
1.6. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 6 Breastfeeding.
1.7
1.7. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 7 Cord pH below normal range.
1.8
1.8. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 8 Abnormal follow‐up in childhood.
1.9
1.9. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 9 Neonatal fitting/seizures.
1.11
1.11. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 11 Apgar score less than seven at five minutes.
1.12
1.12. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 12 Respiratory distress syndrome.
1.13
1.13. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 13 Delivery < 7 days after entry.
1.14
1.14. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 14 Neonatal infection (proven) (outcome not prespecified).
1.15
1.15. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 15 Intracranial pathology (outcome not prespecified).
1.17
1.17. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 17 Other birth trauma (outcome not prespecified).
1.18
1.18. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 18 Head entrapment (outcome not prespecified).
1.19
1.19. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 19 Necrotosing entercolitis (outcome not prespecified).
1.20
1.20. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 20 Cord prolapse (outcome not prespecified).
1.21
1.21. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 21 Need for mechanical ventilation (outcome not prespecified).
1.22
1.22. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 22 Ventilation (days) (outcome not prespecified).
1.23
1.23. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 23 Supplemental oxygen (days) (outcome not prespecified).
1.24
1.24. Analysis
Comparison 1 Planned immediate caesarean section versus planned vaginal delivery in singletons (infant outcomes), Outcome 24 Neonatal jaundice (outcome not prespecified).
2.2
2.2. Analysis
Comparison 2 Planned immediate caesarean section versus planned vaginal delivery in singletons (maternal outcomes)other), Outcome 2 Major maternal postpartum complications.
2.4
2.4. Analysis
Comparison 2 Planned immediate caesarean section versus planned vaginal delivery in singletons (maternal outcomes)other), Outcome 4 Postpartum haemorrhage.
2.5
2.5. Analysis
Comparison 2 Planned immediate caesarean section versus planned vaginal delivery in singletons (maternal outcomes)other), Outcome 5 Maternal puerperal pyrexia (outcome not prespecified).
2.6
2.6. Analysis
Comparison 2 Planned immediate caesarean section versus planned vaginal delivery in singletons (maternal outcomes)other), Outcome 6 Maternal wound infection (outcome not prespecified).
2.7
2.7. Analysis
Comparison 2 Planned immediate caesarean section versus planned vaginal delivery in singletons (maternal outcomes)other), Outcome 7 Other maternal infection (outcome not prespecified).
2.8
2.8. Analysis
Comparison 2 Planned immediate caesarean section versus planned vaginal delivery in singletons (maternal outcomes)other), Outcome 8 Maternal stay more than 10 days (outcome not prespecified).
2.9
2.9. Analysis
Comparison 2 Planned immediate caesarean section versus planned vaginal delivery in singletons (maternal outcomes)other), Outcome 9 Need for blood transfusion (outcome not prespecified).

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