Timing of elective pre-labour caesarean section: Adecision analysis.

Freke A Wilmink,Ben W Mol,Nicole Edge,Eric A.P Steegers,Clarabelle T Pham,Chantal W.P.M Hukkelhoven

doi:10.1111/ajo.12821

Abstract

BackgroundSince caesarean sections (CSs) before 39+0 weeks gestation are associated with higher rates of neonatal respiratory morbidity, it is recommended to delay elective CSs until 39+0 weeks. However, this bears the risk of earlier spontaneous labour resulting in unplanned CSs, which has workforce and resource implications, specifically in smaller obstetric units.AimTo assess, in a policy of elective CSs from 39+0 weeks onward, the number of unplanned CSs to prevent one neonate with respiratory complications, as compared to early elective CS.Materials and MethodsWe performed a decision analysis comparing early term elective CS at 37+0–6 or 38+0–6 weeks to elective prelabour CS, without strict medical indication, at 39+0–6 weeks, with earlier unplanned CS, in women with uncomplicated singleton pregnancies. We used literature data to calculate the number of unplanned CSs necessary to prevent one neonate with respiratory morbidity.ResultsPlanning all elective CSs at 39+0–6 weeks required 10.9 unplanned CSs to prevent one neonate with respiratory morbidity, compared to planning all elective CSs at 38+0–6 weeks. Compared to planning all elective CSs at 37+0–6 weeks we needed to perform 3.3 unplanned CSs to prevent one neonate with respiratory morbidity.ConclusionIn a policy of planning all elective pre‐labour CSs from 39+0 weeks of gestation onward, between three and 11 unplanned CSs have to be performed to prevent one neonate with respiratory morbidity. Therefore, in our opinion, fear of early term labour and workforce disutility is no argument for scheduling elective CSs <39+0 weeks.

Highlights

Rates of caesarean sections (CSs) are increasing in Australia with 33.4% of women birthing by CS in 2015, compared to 28.5% in 2003.1,2 Of all birthing women in 2015, 21% underwent CS prior to labour.[2]
Abstracts and cross-r eferences we identified five cohort studies and one Cochrane review which presented data about neonatal respiratory morbidity following term elective CS stratified by week of gestation from 37+0 weeks of gestation onward (Table 1).[5,8,9,10,19,20]
Pooled incidences of respiratory distress syndrome (RDS) and tachypnoea of the newborn (TTN) were calculated per week of gestation with separate outcome data from three large cohort studies.[8,9,19]

Summary

Introduction

Rates of caesarean sections (CSs) are increasing in Australia with 33.4% of women birthing by CS in 2015, compared to 28.5% in 2003.1,2 Of all birthing women in 2015, 21% underwent CS prior to labour.[2]. Use of a decision analysis tree is a quantitative approach to clinical problem solving that utilises local, national and international data to estimate the probabilities of a certain outcome In this decision analysis we assessed, in a policy of elective CSs from 39+0 weeks onward, the number of unplanned CS that would be required to prevent one infant with respiratory complications. Since caesarean sections (CSs) before 39+0 weeks gestation are associated with higher rates of neonatal respiratory morbidity, it is recommended to delay elective CSs until 39+0 weeks This bears the risk of earlier spontaneous labour resulting in unplanned CSs, which has workforce and resource implications, in smaller obstetric units. Aim: To assess, in a policy of elective CSs from 39+0 weeks onward, the number of unplanned CSs to prevent one neonate with respiratory complications, as compared to early elective CS. In our opinion, fear of early term labour and workforce disutility is no argument for scheduling elective CSs

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Discussion

Conclusion