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Elective Repeat Cesarean Delivery — Do Not Rush

The incidence of neonatal complications was higher for deliveries before 39 weeks’ gestation.

Elective repeat cesarean delivery at term typically is conducted before 39 weeks of gestation only if evidence of fetal lung maturity exists. But, even if the lungs have matured, is delivery before the 39th week associated with elevated risk for neonatal complications? To address this question, investigators studied a cohort of 13,258 consecutive women with singleton pregnancies who underwent elective cesareans at 19 U.S. centers. The primary outcome was a composite measure of neonatal mortality and morbidity, which included respiratory complications, hypoglycemia, neonatal sepsis, and neonatal intensive care unit admission.

Fully 36% of elective cesareans were performed before 39 completed weeks of gestation, and 49% were performed at 39 weeks of gestation. Women who delivered early were more apt to be married, to be white, to have undergone an early ultrasound examination for dating, and to be privately insured. Only one infant (delivered at 39 weeks) died. Risk for neonatal complications rose with decreasing gestational age before 39 weeks; it was 2.1-fold higher at 37 weeks and 1.5-fold higher at 38 weeks than it was at 39 weeks. Although no difference in the incidence of complications was noted between births at 39 weeks and those at 40 weeks, investigators noted a significant trend toward more neonatal complications for deliveries after 40 weeks of gestation.

Comment: An editorialist correctly emphasizes the low risk for any neonatal complication with at-term elective repeat cesarean delivery. However, to do all in our power to limit any complication, we should limit elective repeat cesarean deliveries to the 39th and 40th weeks of gestation — regardless of patients’ desires or physicians’ convenience.

— Robert W. Rebar, MD

Published in Journal Watch General Medicine January 7, 2009

Citation(s):

Tita ATN et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009 Jan 8; 360:111.

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Greene MF. Making small risks even smaller. N Engl J Med 2009 Jan 8; 360:183.

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• Medline abstract (Free)