How often is a low Apgar score the result of substandard care during labour?

To propose suggestions for improvements in care based on conclusions from studies on low Apgar scores and substandard care during labor. Studies on infants with low Apgar scores in a general obstetric population 2004-2006 and claims for financial compensation on the behalf of infants, based on the suspicion that substandard care in conjunction with childbirth has caused severe asphyxia or neonatal death in Sweden 1990-2005. The most common flaws were related to insufficient fetal surveillance, defective interpretation of cardiotocography (CTG) tracings, not acting in a timely fashion on abnormal CTG, and the incautious use of oxytocin. Besides, in half of the infants a suboptimal mode of delivery added further trauma to the already asphyxiated infant. Additionally, resuscitation was unsatisfactory in many of these infants. The most critical flaw was defective compliance with the guidelines concerning ventilation and the early paging of skilled personnel in cases of imminent asphyxia or known complications during labor. In many case reports, the documentation of the neonatal resuscitation was insufficient to enable accurate and reliable evaluation. Examples of proposed improvements in care during labor are the introduction of a permanent educational atmosphere with aside time for daily educational rounds and discussion, cooperation around the use of standardized terminology in CTG interpretation, the cautious use of oxytocin, and the routine paging of a pediatrician before birth in cases of complicated delivery or imminent asphyxia. The proposed interventions need to be evaluated in clinical trials in the future.

ST Analysis of the Fetal ECG, as an Adjunct to Fetal Heart Rate Monitoring in Labour: A Review.

Background: The purpose of intrapartum fetal monitoring by cardiotocograph (CTG) is to identify early signs of developing hypoxia so that appropriate action can be taken to improve the perinatal outcome. Although CTG findings are well known to monitor the progress of the labor due to the paucity of recommendations, there has always been a clinical dilemma as the term fetuses respond differently than a preterm fetus. However, umbilical cord blood pH can distinguish the infant at high risk for asphyxia and related sequel. Therefore, because of differences in fetal physiology in term and preterm fetuses, CTG findings vary, and hence the validity of CTG to determine fetal acidosis should be different. Aims and Objectives: This study aimed to correlate abnormal intrapartum CTG findings with umbilical cord blood pH in term and preterm labor and thus evaluate the success of CTG in predicting fetal acidosis during labor. Methods: The present study included 210 women in labor (70 preterm and 140 term) with abnormal intrapartum CTG that was classified as per 2015 revised International Federation of Gynecologists and Obstetrician (FIGO) guidelines. Immediately after delivery, 2 ml Umbilical artery cord blood sample was taken in a pre-heparinized syringe for analysis, pH <=7.2 was taken as acidosis and pH >7.2 was taken as normal. The measured data were general maternal characteristics which included gravida status, associated comorbidities, method of induction and character of liquor, the intrapartum CTG tracings recorded, the cord arterial blood pH and the neonatal characteristics such as APGAR score and neonatal outcome. Results: Data from 70 preterm labor was compared with 140 term labor. In this study, 20.9% of the babies had acidosis. Suspicious CTG due to decreased variability were more common in the preterm group than in the term group (21.4% vs. 8.6% p<0.05). Positive predictive value (PPV) of abnormal CTG for fetal acidosis in the preterm group was found to be higher than that in the term group, PPV of pathological CTG being even higher than suspicious CTG. Women with suspicious CTG had 82% less risk of fetal acidosis as compared to pathological CTG. Women with Bradycardia had 5.9 times the risk of fetal acidosis as compared with normal and tachycardia. Conclusion: Abnormal CTG should be managed appropriately without any delay to prevent acidosis and cord blood pH should be done in all labors with abnormal CTG. However, our findings of a higher incidence of lower cord blood pH and suspicious CTG due to decreased variability alone highlight the limitation of criteria currently used for interpretation of CTG in preterm labors.

Background: Cardiotocography (CTG) records changes in fetal heart rate and their temporal relation with uterine contractions. Its aim is to diagnose the hypoxia and prioritize the babies who need urgent delivery. Objective: The aim of the study is to assess the role and effectiveness of admission CTG and compare the abnormal and normal CTG regarding fetal outcomes. Methods: It is a prospective observational study held in Z.H. Sikder Women’s Medical College & Hospital for the period of 1 year (July 2020 to June 2021). 500 pregnant women were studied in this period. Admission and intermittent CTG was done according to need. Statistical level of significance was set at p <0.05. Result: Total 500 cases were taken as study population according to inclusion criteria and divided into two groups, normal and abnormal CTG. Abnormal CTG includes both suspicious and pathological varieties. Difference in Apgar score, NICU admission and perinatal asphyxia was statistically significant (p<0.05). Conclusion: A CTG is a non-invasive, reliable and cost-effective screening method to evaluate the fetal condition and to predict perinatal outcome in high risk and also in low-risk pregnancies. Caesarean section rates may be dramatically reduced by appropriate use of CTG.

Background: An important function of cardiotocography (CTG) is to promptly identify non-reassuring fetal status during delivery, as these deviations often prompt primigravidae to undergo a caesarean section. However, these abnormal CTG traces may or may not correspond to intraoperative findings such as meconium-stained liquor or low APGAR scores at birth. It's worth noting that not all abnormal CTG changes result in poor outcomes. Therefore, there is a pressing need for research to explore their correlation, demonstrating the benefits of CTG in accurately detecting non-reassuring fetal status and how it correlates with subsequent intraoperative findings. Aim: To demonstrate the correlation of intra operative findings and fetal outcome in primigravida undergoing caesarean section for non reassuring cardiotocography. Methods: A prospective study of 50 cases of primigravida undergoing emergency caesarean section for non reassuring CTG was taken at the department of Obstetrics and Gynaecology Lalla Ded hospital Srinagar was taken. Their CTG traces were correlated with their intraoperative findings such as meconium stained liquor, cord around neck, oligohydramnios, placental abruption and apgar score at birth. Results: Out of these 50 primigravida who underwent emergency caesarean section,62% had CTG with decelerations-Non reactive, 30% had a CTG trace with persistent decreased variability while 8% had a persistent low baseline on CTG . Among patients with CTG trace showing decelerations 58% had meconium stained liquor, 16.5% had cord around the neck and 25.8 % had low APGAR scores at birth . Among the group of patients with decreased variability 42.1% had meconium stained liquor, 10.5% had cord around the neck and 21% had low APGAR scores at birth. Among the group with low baseline, 51% had meconium stained liquor, 23% had cord around neck and 39 % had low birth apgar. Conclusion: Cardiotocography shows a positive correlation with meconium-stained liquor and APGAR scores at birth, but not with cord entanglements. Therefore, it's crucial to use CTG judiciously and consider employing other non-invasive, cost-effective tests to detect non-reassuring fetal status, aiming to reduce unnecessary caesarean sections.

Background: Cardiotocography (CTG) is used on a regular basis to check on fetal health, but it remains a topic of investigation for fetal-neonatal outcome correlation and low Apgar scores. Abnormal CTG patterns like fetal tachycardia, fetal bradycardia, and decelerations can signify fetal distress and are correlated with poor neonatal health. Objective: To determine the frequency of Low Apgar score in patient having abnormal cardiotocography. Study Design: Descriptive study. Duration and Place of Study: The study was conducted from March 2023 to September 2023 at the Department of Obstetrics and Gynaecology, Saidu Group of Teaching Hospital Swat. Methodology: 107 pregnant women aged between 18 and 40 with singleton gestations and abnormal CTG were selected using a non-probability consecutive sampling. Demographic data such as maternal age, gestation age, parity and Apgar scores at 5 minutes of delivery were collected. Descriptive statistics and Chi-square tests were employed to associate low Apgar scores (≤5) with demographic parameters with a p-value of ≤0.05 considered to be statistically significant. Results: The mean age of the participants was 28.37 ± 3.08 years, the mean gestational age was 37.11 ± 1.95 weeks, and the mean parity was 1.71 ± 1.47. Of the 107 participants, 76 (71%) had a low Apgar score, while 31 (29%) had a normal score. No significant association was found between low Apgar scores and age, gestational age, or parity (p-values of 0.847, 0.688, and 0.993, respectively). Conclusion: Abnormal CTG is associated with a high frequency of low Apgar scores.

Despite the advancements in perinatal care in past decades, perinatal asphyxia remains a serious problem leading to significant perinatal morbidity and mortality. Therefore, foetal monitoring during the intrapartum period is of paramount importance. Among various methods of fetal monitoring, cardiotocography is a form of electronic foetal monitoring in which there is simultaneous recording of foetal heart rate and uterine contractions. This cross-sectional observational study was done in the labour room and neonatal intensive care unit (NICU) of a teaching Municipal Hospital in North India including 500 pregnant women of age group 18-45 years with singeleton fetus of gestation ≥36 weeks without any known congenital anomaly. Intrapartum cardiotocography (CTG) for 20 minutes was done within 12 hours prior to delivery and babies born to them were observed for birth asphyxia as Apgar score <7 at 1 minute as per using APGAR score less than 7 at 1 minute as per south east asia regional neonatal perinatal database (SEAR-NPD), world health organization (WHO) working definition. CTG tracing was normal/reassuring in 92% of pregnant women, nonreassuring in 7% and was abnormal in only 1%. In patients with abnormal and nonreassuring CTG, delivery by lower segment cesarian section (LSCS) was significantly high (P < .0001). APGAR scoring was done at 1 minute and 5 minutes of life, it was found that 4% babies were having score less than 7 at 1 minute with incidence of birth asphyxia 40 per 1,000 live births Neonatal seizure was significantly more in nonreassuring and abnormal CTG group (P value <.0001). Abnormal CTG tracings result in higher incidence of operative interventions for deliveries. Abnormal CTG pattern during intrapartum CTG has high specificity and negative predictive value but has low sensitivity and positive predictive value for detection of birth asphyxia and need for NICU admission.

The goal of this study was to investigate the association of poor birth condition with long-term social and economic outcomes at 25 to 31 years of age. This was a population-based cohort study using data derived from linkage of routinely collected Swedish data. All term infants born in Sweden between 1973 and 1979 identified from the Swedish birth registry (n = 651 615) were included in the study. Infants were categorized into 3 groups: (1) infants with a normal (>7) Apgar score at 1 or 5 minutes of age without encephalopathy; (2) infants with a low (<7) Apgar score at 1 and 5 minutes of age without encephalopathy; and (3) infants with a low (<7) Apgar score at 1 and 5 minutes with evidence of encephalopathy. The main outcome measures were achievement of a university education and participant's income in early adulthood. Infants with low Apgar scores who did not develop encephalopathy were less likely to have attended university (odds ratio [OR]: 1.14 [95% confidence interval (CI): 1.05-1.23]) and were more likely to have no income from work (OR: 1.19 [95% CI: 1.07-1.32]) than those born in good condition. Infants who developed encephalopathy also had greater risks of these adverse outcomes (not attended university, OR: 1.94 [95% CI: 1.13-3.33]); no income from work, OR: 3.08 [95% CI: 1.89-5.01]). Infants born in poor condition had worse measures of social performance than their peers, and this association was not restricted to those infants who developed obvious neurologic symptoms in the neonatal period. However, even in infants with likely encephalopathy, more than half obtained employment and one third attended university.

Fetal hypoxia can cause damaging consequences on babies' such as stillbirth and cerebral palsy. Cardiotocography (CTG) has been used to detect intrapartum fetal hypoxia during labor. It is a non-invasive machine that measures the fetal heart rate and uterine contractions. Visual CTG suffers inconsistencies in interpretations among clinicians that can delay interventions. Machine learning (ML) showed potential in classifying abnormal CTG, allowing automatic interpretation. In the absence of a gold standard, researchers used various surrogate biomarkers to classify CTG, where some were clinically irrelevant. We proposed using Apgar scores as the surrogate benchmark of babies' ability to recover from birth. Apgar scores measure newborns' ability to recover from active uterine contraction, which measures appearance, pulse, grimace, activity and respiration. The higher the Apgar score, the healthier the baby is.We employ signal processing methods to pre-process and extract validated features of 552 raw CTG. We also included CTG-specific characteristics as outlined in the NICE guidelines. We employed ML techniques using 22 features and measured performances between ML classifiers. While we found that ML can distinguish CTG with low Apgar scores, results for the lowest Apgar scores, which are rare in the dataset we used, would benefit from more CTG data for better performance. We need an external dataset to validate our model for generalizability to ensure that it does not overfit a specific population.Clinical Relevance- This study demonstrated the potential of using a clinically relevant benchmark for classifying CTG to allow automatic early detection of hypoxia to reduce decision-making time in maternity units.

Background: Elaborate Cardiotocography (CTG) is the most commonly used test for antepartum and intrapartum fetal surveillance because it gives information via the cerebro-cardiac response of fetal cerebral activity, which is modified by the hypoxia. Objective: This study was designed to compare the perinatal outcomes among the normal and abnormal CTG groups. Method: It was a prospective observational study carried out in the Department of obstetrics, BSMMU during the period July 2006 to July 2008. Hundred consecutive normal and hundred consecutive abnormal CTC tracings were collected from patients who were advised to perform CTG after admission. Both labour and non-labour patients were included. Interpretation of CTG was done based on FlGO recommendation (1987). Pregnancy and neonatal data were obtained and the findings were correlated with the FHR tracing. Statistical analysis was carried out by student's unpaired t-test, X 2 and Z-test. Level of significance was set at P value < 0.05. Results: Out of 100 abnormal CTG, 30% had tachycardia, 42% had deceleration, 38% was non reactive, 4% had absence beat-to-beat variability and 4% had fetal bradycardia. There was significantly higher caesarean delivery, lower apgar score, higher requirement of neonatal resuscitation and admission at neonatal unit and higher perinatal death among the abnormal CTG group. The abnormal fetal outcome was found highest in heart rate deceleration group. Conclusion: CTG can be continued as a good screening test of fetal surveillance but it is not the sole criteria to influence the management of high-risk pregnancies. Abnormal CTG should be supplemented with other test before intervention. Key words: CTG; Perinatal outcome. DOI: 10.3329/bsmmuj.v2i1.3706 BSMMU J 2009; 2(1): 18-24

Continuous fetal heart rate monitoring by cardiotocography (CTG) is used in labour for women with complicated pregnancies. Fetal heart rate abnormalities are common and may result in the decision to expedite delivery by caesarean section. Fetal scalp stimulation (FSS) is a second-line test of fetal well-being that may provide reassurance that the labour can continue. To evaluate methods of FSS as second-line tests of intrapartum fetal well-being in cases of non-reassuring CTG. FSS and CTG were compared to CTG alone, and to CTG with fetal blood sampling (FBS). We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, the WHO ICTRP and conference proceedings), ClinicalTrials.gov (18 October 2022), and reference lists of retrieved studies. Eligible studies were randomised controlled trials (RCTs) that compared any form of FSS to assess fetal well-being in labour. Quasi-RCTs, cluster-RCTs and studies published in abstract form were also eligible for inclusion, but none were identified. Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. Two trials, involving 377 women, met the inclusion criteria for this review. Both trials were conducted in hospital settings and included women with singleton, term (37+0 weeks or more) pregnancies, a cephalic presentation, and abnormal CTG. Follow-up was until hospital discharge after the birth. A pilot trial of 50 women in a high-income country (Ireland) compared CTG and digital fetal scalp stimulation (dFSS) with CTG and fetal blood sampling (FBS). A single-centre trial of 327 women in a lower middle-income country (India) compared CTG and manual fetal stimulation (abdominal or vaginal scalp stimulation) with CTG alone. The two included studies were at moderate or unclear risk of bias. Both trials provided clear information on allocation concealment but it was not possible to blind participants or health professionals in relation to the intervention. Although objective outcome measures were reported, outcome assessment was not blinded or blinding was unclear. dFSS and CTG versus FBS and CTG There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. The risk of caesarean section (CS) may be lower with dFSS compared to FBS (risk ratio (RR) 0.38, 95% confidence interval (CI) 0.16 to 0.92; 1 pilot trial, 50 women; very low-certainty evidence) but the evidence is very uncertain. There were no cases of neonatal encephalopathy reported. The evidence was also very uncertain between dFSS and FBS for assisted vaginal birth (RR 1.44, 95% CI 0.76 to 2.75; very low-certainty evidence) and for the spontaneous vaginal birth rate (RR 2.33, 95% CI 0.68 to 8.01, very low-certainty evidence). Maternal acceptability of the procedures was not reported. FSS and CTG versus CTG alone Manual stimulation of the fetus was performed either abdominally (92/164) or vaginally (72/164). There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. There may be little differences in the risk of CS on comparing manual fetal stimulation and CTG with CTG alone (RR 0.83, 95% CI 0.59 to 1.18; 1 trial, 327 women; very low-certainty evidence), but again the evidence was very uncertain. There were no cases of neonatal encephalopathy reported. There may be no differences in the risk of assisted vaginal birth (RR 1.43, 95% CI 0.78 to 2.60; very low-certainty evidence) or in the rates of spontaneous vaginal birth (RR 1.01, 95% CI 0.85 to 1.21, very low-certainty evidence), but again the evidence is very uncertain. Maternal acceptability of abdominal stimulation/FSS was not reported although 13 women withdrew consent after randomisation due to concerns about fetal well-being. There is very low-certainty evidence available which makes it unclear whether stimulating the fetal scalp is a safe and effective way to confirm fetal well-being in labour. Evidence was downgraded based on limitations in study design and imprecision. Further high-quality studies of adequate sample size are required to evaluate this research question. In order to be generalisable, these trials should be conducted in different settings, including broad clinical criteria at both preterm and term gestational ages, and standardising the method of stimulation. There is an ongoing study (FIRSST) that will be incorporated into this review in a subsequent update.

The aim was to investigate if intrapartum monitoring with cardiotocography (CTG) in combination with ST analysis (STAN) results in an improved perinatal outcome. We performed a two-center randomized trial. 1013 women with term fetuses in cephalic presentation entered the trial. If a CTG showed intermediate or pathological abnormalities, they were offered fetal blood sampling (FBS) and inclusion if the pH value was above 7.25. They were randomized to either CTG + FBS or CTG + STAN. The primary outcome was neonatal metabolic acidosis, defined as umbilical cord arterial blood pH below 7.05, and base excess equal to or below -10. The secondary outcomes included operative vaginal delivery for fetal distress. The rate of metabolic acidosis was 0.8% in the CTG + FBS group and 1.5% in women in the CTG + STAN (P = 0.338). More women in the CTG + STAN group delivered by operative vaginal delivery (25.6% vs 33.5%, P = 0.006). Significantly fewer women in the CTG + STAN group had three to five (28.8% vs 11.0%, P = < 0.001) and six to ten fetal blood samples taken (3.4% vs 0.4%, P = < 0.001). CTG + STAN did not reduce the incidence of neonatal metabolic acidosis compared to CTG + FBS. CTG + STAN was, however, associated with an increased risk of operative vaginal delivery and a reduced use of FBS. If STAN is used for fetal surveillance, we recommend that it is combined with other methods, such as FBS, for confirmation of the need for operative delivery. gov ID: NCT01699646. Date of registration: October 4, 2012 (retrospectively registered). https://clinicaltrials.gov/ct2/show/NCT01699646?id=NCT01699646&draw=2&rank=1.

Background: Intrapartum assessment of the fetus is a challenging task. And a good fetal surveillance during labour often entails monitoring the fetal heart rate with cardiotocography (CTG). The fetal heart rate pattern is an indicator of medullary response of fetal brain to the acidemia, blood volume changes and hypoxemia, as the brain modulates the fetal heart rate. But specificity of CTG is low that’s why generally intrapartum cardiotocography is combined with a second variable, such as Fetal Scalp Blood sampling, to improve its specificity. The increased intervention rates associated with non-reactive cardiotocography can be reduced with the use of fetal scalp blood sampling. Objectives: To compare frequency of caesarean section with use of non- reactive Cardiotocography versus non-reactive Cardiotocography and fetal scalp blood sampling. To determine the immediate neonatal outcome in terms of death, Apgar score and need for intensive care unit admission after delivery. Study Design: This study was cross sectional analytical study. Settings: Obstetrics and Gynaecology department, Unit-I, Lady Willingdon Hospital, Lahore, affiliated with King Edward Medical University. Duration: The duration of study was 1 year. Methodology: The non-probablity purposive sampling technique was used in this study. 100 patients in labour at term presented to labour room of Lady Willingdon Hospital, and fulfilling the inclusion criteria were enrolled in this study. After taking informed written consent, the patients were divided into two groups (A and B). In group A, 50 cases having non-reactive Cardiotocography were taken and according to fetal assessment by Cardiotocography all were taken for caesarean section. In group B, 50 cases having non-reactive Cardiotocography were taken and fetal assessment was done by continuous Cardiotocography as well as fetal scalp blood sampling. In group B, fetal hypoxia was assessed by fetal blood pH. Only those cases in group B underwent caesarean section, where fetal hypoxia was confirmed by fetal blood pH (pH=<7.20). Apgar score at 1 min and 5 min and admission to neonatal intensive care unit (NICU) was noted for postnatal fetal assessment in both the groups. Data was entered and analyzed through SPSS version 21. To calculate sensitivity, specificity, Positive predictive value (PPV), negative predictive value (NPV) and fetal scalp blood pH 2x2 tables were generated, taking pH as gold standard. Results: In this study among 100 patients, the mean age of the patients was noted as 27.64±4.38 years and the mean gestational age was noted as 39.30±1.05 weeks. The mean Apgar score at 1 minute of the baby was noted as 5.62±1.39, whereas at 5 minutes was noted as 6.76±2.09. In group B among 50 cases the mean pH value of fetal scalp blood was noted as 7.25±0.048. Fetal scalp blood sampling was normal in 20/50 (40%) patients, borderline in 24/50 (48%) patients, whereas it was abnormal in 6/50 (12%) patients. In group A, among 50 cases all underwent lower segment Caesarean section (LSCS). In group B, among 50 cases, 30/50 (60%) cases underwent LSCS while 20/50 (40%) underwent spontaneous vaginal delivery. In group A, 28/50 (56%) cases had Apgar <7 at 5 minutes while in group B, 18/50 (36%) cases had Apgar <7 at 5 minutes. In group A, 4/50 (8%) cases died while in group B, no mortality was observed. There was significant difference observed between group A and cases in group B for all these factors. In group A, 10/50 (20%) cases had NICU admission while in group B, only 6/50(12%) cases had NICU admission. There was no significant difference observed between two groups in NICU admission. Conclusion: It was concluded that CTG coupled with fetal blood sampling for fetal pH versus carditocography alone is an accurate method for assessment of fetal condition in labour to decide the mode of delivery and neonatal outcome after birth.

Background: Cardiotocography (CTG) is a cornerstone of intrapartum fetal monitoring and plays a vital role in assessing fetal well-being during labor. Abnormal CTG patterns—such as elevated baseline fetal heart rate, reduced variability, and decelerations—are commonly linked to adverse neonatal outcomes, including low birth weight, decreased 5-minute APGAR scores, increased neonatal intensive care unit (NICU) admissions, and perinatal mortality. Despite its widespread use in tertiary care, the effectiveness of CTG relies heavily on accurate and timely interpretation to reduce unnecessary interventions and improve perinatal outcomes. Objective: To evaluate fetal outcomes associated with pathological intrapartum CTG among term pregnant women at Abbasi Shaheed Hospital, Karachi. Methods: A descriptive cross-sectional study was conducted over six months and included 133 laboring women at term (gestational age ≥37 weeks) with singleton pregnancies and maternal age ranging from 20 to 45 years. CTG was defined as pathological when the baseline fetal heart rate exceeded 170 bpm, variability was less than 5 bpm, or early, prolonged, or late decelerations were observed. All participants underwent standardized corrective interventions, including maternal repositioning and oxygen therapy. Data were collected using structured forms and analyzed using SPSS version 20. Associations between CTG patterns and fetal outcomes were assessed using Chi-square and Fisher’s exact tests, with statistical significance set at p ≤ 0.05. Results: Among 133 patients, 24 (18%) neonates had low birth weight, 33 (25%) had low 5-minute APGAR scores, 13 (10%) required NICU admission, and 4 (3%) experienced in-hospital mortality. The presence of late decelerations was significantly associated with low APGAR scores (p=0.004) and NICU admissions (p=0.012). Conclusion: Pathological CTG patterns strongly predict adverse neonatal outcomes. Timely recognition and standardized responses can enhance perinatal safety in resource-constrained tertiary care settings.

Due to the high incidence of neonatal complications in diabetic pregnancies, the aim of our study was to investigate whether elective cesarean section could prevent adverse neonatal outcome. Population-based study. Data were extracted from the Swedish Medical Birth Registry. All women (n=13 491) with diabetic pregnancies during the period 1990-2007. Neonatal outcome in diabetic pregnancies was compared after elective cesarean section at 38 completed gestational weeks with planned vaginal delivery at 39 completed weeks of gestation or later. Odds ratios with 95% confidence intervals for Apgar scores <7 at 5 min after birth were calculated using multiple logistic regression. Apgar score <7 at 5 min after birth. A significantly decreased risk of Apgar score <7 at 5 min after birth in the group who underwent an elective cesarean section at 38 completed gestational weeks was found compared with those who continued pregnancy to 39 completed weeks of gestation or more, irrespective of final mode of delivery. Our results indicate a protective effect of planned cesarean section on the risk of low Apgar scores in diabetic pregnancies.