Vaginal Birth Group Research Articles

Birth after caesarean study--planned vaginal birth or planned elective repeat caesarean for women at term with a single previous caesarean birth: protocol for a patient preference study and randomised trial.

BackgroundFor women who have a caesarean section in their preceding pregnancy, two care policies for birth are considered standard: planned vaginal birth and planned elective repeat caesarean. Currently available information about the benefits and harms of both forms of care are derived from retrospective and prospective cohort studies. There have been no randomised trials, and recognising the deficiencies in the literature, there have been calls for methodologically rigorous studies to assess maternal and infant health outcomes associated with both care policies.The aims of our study are to assess in women with a previous caesarean birth, who are eligible in the subsequent pregnancy for a vaginal birth, whether a policy of planned vaginal birth after caesarean compared with a policy of planned repeat caesarean affects the risk of serious complications for the woman and her infant.Methods/DesignDesign: Multicentred patient preference study and a randomised clinical trial.Inclusion Criteria: Women with a single prior caesarean presenting in their next pregnancy with a single, live fetus in cephalic presentation, who have reached 37 weeks gestation, and who do not have a contraindication to a planned VBAC.Trial Entry & Randomisation: Eligible women will be given an information sheet during pregnancy, and will be recruited to the study from 37 weeks gestation after an obstetrician has confirmed eligibility for a planned vaginal birth. Written informed consent will be obtained. Women who consent to the patient preference study will be allocated their preference for either planned VBAC or planned, elective repeat caesarean. Women who consent to the randomised trial will be randomly allocated to either the planned vaginal birth after caesarean or planned elective repeat caesarean group.Treatment Groups: Women in the planned vaginal birth group will await spontaneous onset of labour whilst appropriate. Women in the elective repeat caesarean group will have this scheduled for between 38 and 40 weeks.Primary Study Outcome: Serious adverse infant outcome (death or serious morbidity).Sample Size: 2314 women in the patient preference study to show a difference in adverse neonatal outcome from 1.6% to 3.6% (p = 0.05, 80% power).Clinical Trial RegistrationISCTRN5397431

Neonatal and Maternal Outcomes in Twin Gestations ???32 Weeks According to the Planned Mode of Delivery

Rates of both perinatal morbidity and mortality are higher in twins than in singleton infants, chiefly because of low birth weight and prematurity as well as twin-twin transfusion syndrome. Malpresentation and mode of delivery remain important factors. Although planned cesarean section may be effective if there is a breech presentation or to prevent locked twins, there is no prevailing opinion about the best mode of delivery. This retrospective cohort study dealt with a total of 164 twins at or after 32 weeks gestation seen at a single center in the years 1999-2002. Cesarean delivery was performed in 29 women (17.7%), the most common indication being fetal malpresentation. In the remaining 135 twins (82.3%), vaginal delivery was attempted, but 26 women required emergent or urgent cesarean section for delivery of both infants. Two women required emergency section for twin B only. Thirteen A twins had instrumental delivery, most often because of fetal distress or failure to progress. One in five women who were to have planned vaginal birth required section delivery; the success rate in the planned vaginal birth group was nearly 80%. There was a single fetal death. Twins A had more serious morbidity in the planned vaginal birth group than with elective cesarean section, but the difference was not significant. Twins B had increased neonatal morbidity regardless of the planned mode of delivery. No women had major life-threatening illness. Two women required a second laparotomy, but rates of serious morbidity did not differ significantly in the planned cesarean section and planned vaginal birth groups (13.8% and 19.3%, respectively). These findings fail to support elective operative delivery for twin gestations at 32 or more weeks gestation. Planned vaginal delivery succeeded in nearly 80% of cases. A prospective, randomized trial may be needed to settle this question.

Birth insults involving hypoxia produce long-term increases in hippocampal [ 125I]insulin-like growth factor-I and -II receptor binding in the rat

Insulin-like growth factors-I and -II and insulin are structurally related mitogenic growth factors with multiple actions in the developing nervous system and adult CNS. Previous studies have demonstrated acute induction of insulin-like growth factors and their receptors, over a time course of several days, in response to hypoxic/ischemic insult to developing or adult brain. The current study tested whether birth insults involving hypoxia may produce long term changes in brain insulin-like growth factor or insulin receptor levels, lasting into adulthood. For this, rats were born vaginally (controls), by cesarean section, or by cesarean section with 15 min of added global anoxia (cesarean section+anoxia), and brain [ 125I]insulin-like growth factor-I, [ 125I]insulin-like growth factor-II and [ 125I]insulin receptor binding sites were assessed autoradiographically at adulthood. [ 125I]Insulin-like growth factor-I receptor binding sites were increased in all hippocampal subfields (CA1–CA3, dentate gyrus) in rats born either by cesarean section or by cesarean section+anoxia, compared with vaginal birth. [ 125I]Insulin-like growth factor-II binding was increased in all hippocampal subfields only in rats born by cesarean section+anoxia compared with either vaginal birth or cesarean section groups. [ 125I]Insulin-like growth factor-I and [ 125I]insulin-like growth factor-II binding in frontal cortex, striatum and cerebellum were unaffected by birth group, except for increased [ 125I]insulin-like growth factor-I binding in the cerebellar molecular layer of cesarean-sectioned animals. Birth group had no significant effect on [ 125I]insulin binding in any brain region. Affinity cross-linking experiments performed with hippocampal membranes from the three birth groups showed that i) [ 125I]insulin-like growth factor-I and [ 125I]insulin-like growth factor-II recognized bands of molecular weights characteristic of insulin-like growth factor-I and insulin-like growth factor-II receptors, respectively, and ii) [ 125I]insulin-like growth factor-I and [ 125I]insulin-like growth factor-II were displaced more potently by their respective unlabeled ligands than by related molecules. It is concluded that birth insults involving hypoxia can induce lasting increases in insulin-like growth factor-I and -II receptors in the CNS. There is specificity with respect to the subtype of insulin-like growth factor receptor affected by the particular birth insult and the brain region affected. It is suggested that enduring increases in levels of insulin-like growth factor receptors consequent to hypoxic birth insult may help to maintain hippocampal function at adulthood, and could modulate responsiveness to insulin-like growth factor administration.

Pronostic obstétrical et néonatal d’une présentation podalique de mauvaise réputation : le siège complet

A nonfrank breech is generally believed to be associated with abnormal labor and risk of cord prolapse. Owing to these risks, many authors consider such a presentation as a positive indication for cesarean section. The purpose of this study was to estimate the delivery characteristics of nonfrank breech with a gestational age over 37 weeks and particularities of this presentation. This retrospective study included all deliveries with a nonfrank breech presentation and a gestational age over 37 weeks over a sixteen years period in our maternity ward. A descriptive analysis of maternal, fetal and obstetrical elements was carried out. 198 deliveries were indexed with 54% vaginal birth, regularly observed throughout the study period. Thirty percent delivered by prelabor planned cesarean section and 16% by cesarean section during labor. When a vaginal birth trial was allowed, at last 77.4% delivered by this route. Average labor time in the vaginal birth group was only 4.5 hours. Eleven cord prolapses were found (5.6%) of which more than half delivered by vaginal birth without fetal complications. Perinatal outcomes were satisfactory for the whole population, without differences between cesarean section and vaginal birth. Cord prolapse is a risk of nonfrank breech presentation but abnormal labor is not more frequent than with frank breech presentations if labor is managed rigorously. More than 75% patients of the vaginal birth trial group delivered by vaginal birth with perinatal outcomes as good as the cesarean section group. Unlike traditional reports, in our study a nonfrank breech was not an unfavorable factor for vaginal birth after strict selection of vaginal birth trial candidates.

The costs of planned cesarean versus planned vaginal birth in the term breech trial

The Term Breech Trial was an international multicenter randomized controlled trial comparing a policy of planned cesarean and a policy of planned vaginal birth for breech presentations at term. The study found that the combined outcome of perinatal mortality, neonatal mortality, or serious neonatal morbidity was lower for the planned cesarean group than for the planned vaginal birth group, and that there were no differences between groups in maternal mortality or serious maternal morbidity. We undertook a cost analysis comparing the policy of planned cesarean and the policy of planned vaginal birth for breech presentations at term in the Term Breech Trial.

Neonatal and maternal outcomes in twin gestations ≥32 weeks according to the planned mode of delivery

Objective To determine a possible relationship between neonatal and maternal outcomes in twin gestations and the planned mode of delivery. Study design A single-centre retrospective cohort study in twins ≥32 weeks of gestational age was performed. Baseline characteristics, and neonatal and maternal outcomes were documented according to the planned mode of delivery: a planned caesarean section or a planned vaginal birth. Statistical analysis was performed using chi-square test. Fisher exact test was used in case correction was needed. Results During the study period (1999–2002), 164 twins ≥32 weeks were enrolled in the study. In 29 women (17.7%) an elective caesarean section was performed. The remaining 135 twins (82.3%) were allowed to start a vaginal delivery. An emergency or an urgent secondary caesarean section for both twins was performed in 26 women, and in 2 women for twin B only. One twin B baby died during planned vaginal delivery. No significant differences in perinatal mortality and serious neonatal morbidity were found between both groups (10.3% versus 9.6%). Neonatal outcomes in twins A were significantly better than in twins B (2.4% versus 7.3%), independent of the planned mode of delivery. Serious maternal morbidity was not significantly different between both groups (13.8% versus 19.3%), although 2 women in the elective caesarean section group needed a relaparotomy for haemorrhage. Conclusion Our results do not support an elective caesarean section for twin gestations ≥32 weeks. The success rate of vaginal delivery in the planned vaginal birth group was nearly 80%.

A Comparison of Urinary and Sexual Outcomes in Women Experiencing Vaginal and Caesarean Births

Objective: To evaluate the urinary and sexual consequences of vaginal delivery compared with Caesarean section.Methods: We performed a cohort analysis of data from a randomized controlled trial of episiotomy conducted in 3 Montreal hospitals in 1990–1991. Of the 999 trial participants for whom follow-up data were available, 135 delivered by Caesarean section (CS), and 864 had a vaginal birth (VB). After stratifying for parity, we compared rates of urinary incontinence (UI) and sexual functioning at 3 months postpartum in women who had a VB with the rates in women who had a CS.Results: Primiparous women reported unspecified UI at 3 months postpartum more often (17.9%) in the VB group than in the CS group (6.4%). This difference remained significant whether or not there was a prior history of UI. Multiparous women showed no difference in rates of UI (VB 17.1% vs. CS 16.0%), whether there was a prior history of UI or not. Stress incontinence was greater among primiparous women in the VB group (VB 34.5% vs. CS 12.8%) regardless of prior UI history, but the proportion of women whose UI was severe enough to wear a pad was similar in primiparous women (VB 16.0%, CS 15.4%) and multiparous women (VB 23.8%, CS 25.0%). Women’s sexual dissatisfaction was greater among primiparous women who had a vaginal birth (VB 70.1%, CS 54.5%), but in multiparous women, the rates of sexual dissatisfaction were similar (VB 64.2%, CS 71.4%). The frequency of dyspareunia for each mode of delivery was similar in primiparous women (VB 30.7%, CS 31.6%). Overall, both primiparous and multiparous women who had intact perineums after VB had less dyspareunia than those undergoing CS (VB 26.2, CS 40.7%). However, the proportion of women experiencing dyspareunia was greatest among those who had an episiotomy with or without forceps.Conclusion: At 3 months postpartum, delivery by CS appeared to afford some protection against unspecified and stress UI, but severe UI was similar in the VB and CS groups. Overall sexual functioning following VB and CS was similar, but women who had an episiotomy with or without forceps experienced less favourable sexual outcomes at 3 months postpartum than did the women who had an intact perineum or a second-degree tear, or who had had a Caesarean section.

Mothers’ Views of Their Childbirth Experiences 2 Years Mter Planned Caesarean Versus Planned Vaginal Birth for Breech Presentation at Term, in the International Randomized Term Breech Trial

Objective: To compare mothers’ views at 2 years postpartum after participation in a randomized trial of planned Caesarean and planned vaginal birth for a singleton fetus in breech presentation at term.Study Design: In selected centres in the Term Breech Trial, mothers completed a structured questionnaire at approximately 2 years postpartum to assess their likes and dislikes about their childbirth experiences and their views about their intrapartum care and care providers.Results: Of 1159 mothers from 85 centres, 917 (79.1%) completed a follow-up questionnaire at 2 years postpartum. Baseline information was similar for both the planned Caesarean and planned vaginal birth groups. Planned Caesarean was associated with less worry about the baby’s health (P < 0.001). While other differences were noted in likes and dislikes about their childbirth experiences, women’s evaluations of the quality of intrapartum care, the helpfulness of staff, and their involvement in decision-making did not differ in the planned Caesarean delivery and planned vaginal birth groups.Conclusion: Planned mode of delivery influences aspects of women’s evaluations of their childbirth experiences but does not affect evaluations of the quality of intrapartum care, support from care providers, or amount of involvement in decision-making.

Elective cesarean section for preterm intrauterine growth retarded fetuses

When a preterm delivery is unavoidable as a consequence of a fetal or maternal indication cesarean section without a trial of labor can be assigned as elective. Elective cesarean section to deliver an IUGR fetus may help to achieve better neonatal outcome. This study was performed for the assessment this proposal and aimed to evaluate impact of the elective cesarean procedure for the early outcome of IUGR fetuses. The birth records between 1995 and 1999 were reviewed in Istanbul University Cerrahpasa School of Medicine Obstetrics and Gynecology Department. The records of 112 cases were fulfilled the study criteria (singleton IUGR-below 10% birth weight-baby in vertex presentation born with elective cesarean section or vaginal birth between 33 and 37 gestational weeks) and analyzed. Mean gestational age was 35.5 weeks and the mean birth weight was 1998 g (800-2470) in the whole group. The NICU admission rate was highest in the 1500-1999 g birth weight group (19/26 73.1%) (Table 1). The births were divided into vaginal delivery (n=66) and cesarean section (n=46) groups. The neonatal outcomes were compared. The rate of NICU admission was higher in the cesarean section group than the vaginal birth group (16/46 34.8% versus 10/66 15.2% respectively) (p>0.05) (Table 2). There was only one case died in the vaginal birth group due to RDS. (excerpt)

Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: The international randomized Term Breech Trial

The purpose of this study was to determine whether planned cesarean delivery for the singleton fetus in breech presentation at term reduces the risk of death or neurodevelopmental delay at 2 years of age. In selected centers in the Term Breech Trial, children were screened for abnormalities at > or =2 years of age with the Ages and Stages Questionnaire, followed by a neurodevelopmental assessment if the Ages and Stages Questionnaire score was abnormal. A total of 923 of 1159 children (79.6%) from 85 centers were followed to 2 years of age. The risk of death or neurodevelopmental delay was no different for the planned cesarean than for the planned vaginal birth groups (14 children [3.1%] vs 13 children [2.8%]; relative risk, 1.09; 95% CI, 0.52- 2.30; P = .85; risk difference, +0.3%; 95% CI, -1.9%, +2.4%). Planned cesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age.

Vaginal birth after cesarean delivery: An historic cohort cost analysis

Objective: The purpose of this study was to evaluate the relative cost-effectiveness of attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery. Study Design: We performed an historic cohort analysis of women with a single prior cesarean delivery who were delivered at our institution during 1999. Inclusion criteria were ≥36 weeks' gestation and carrying a live, singleton fetus with no antenatally diagnosed anomalies. The primary outcome variable was mean cost of hospital care for mother-infant pairs, as obtained from the hospital's Clinical Resources Department. Results: The cohort consisted of 204 mother-infant pairs, 65 in the elective repeat cesarean group and 139 in the attempted vaginal birth group. Mean cost of care was higher for mothers ($4155 vs $3675;P <.001), neonates ($1794 vs $1187; P =.03), and mother-infant pairs ($5949 vs $4863; P =.001) for the elective repeat cesarean group compared with the attempted vaginal delivery group. Conclusion: In women with a single prior cesarean delivery, a trial of labor is more cost-effective than an elective repeat cesarean delivery. (Am J Obstet Gynecol 2002;186:890-2)

Planned Caesarean Section Versus Planned Vaginal Birth for Breech Presentation at Term: A Randomised Multicentre Trial

Hannah, Mary E.; Hannah, Walter J.; Hewson, Sheila A.; Hodnett, Ellen D.; Saigal, Saroj; Willan, Andrew R. for the Term Breech Trial Collaborative Group

Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial

For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies. At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat. Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35). Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

Glutathione S-transferase Alpha 1-1 and aminotransferases in umbilical cord blood.

Recent data suggest that levels of glutathione S-transferase Alpha 1-1 in umbilical cord plasma may be a good indicator of neonatal hepatocellular integrity. In order to fully understand the significance of this new marker we compared the values of glutathione S-transferase Alpha 1-1 (GSTA1-1) with that of the well known liver function markers alanine aminotransferase (ALT) and aspartate aminotransferase (AST) in arterial and corresponding venous umbilical cord blood of 93 patients. In addition, in 49 of these patients maternal venous blood was also studied. Both arterial and venous umbilical cord GSTA1-1 and AST levels were significantly higher than corresponding maternal venous levels, whereas ALT levels were not. Arterial umbilical cord GSTA1-1 correlated significantly with the corresponding AST and ALT levels (R = 0.46, P < 0.0001 and R = 0.41, P < 0.0001, respectively). Arterial umbilical cord AST correlated significantly with corresponding ALT levels (R = 0.58, P < 0.0001). Arterial umbilical cord plasma GSTA1-1 levels were significantly lower in the cesarean delivery group as compared to the vaginal birth group, whereas no difference was noted for AST or ALT. Arterial umbilical cord AST and GSTA1-1 levels correlated significantly with base deficit (R = 0.29, P = 0.005; R = 0.29, P = 0.005, respectively), whereas ALT did not (R = 0.06, P = 0.54). Arterial umbilical cord AST, ALT, and GSTA1-1 levels correlated significantly with birthweight. In conclusion, GSTA1-1 levels as assessed in neonatal umbilical cord blood, being unrelated to maternal levels, seem to be a more sensitive marker for early neonatal hepatocellular integrity as compared to ALT or AST and even might detect impaired hepatocellular integrity due to the vaginal birth process. Umbilical cord GSTA1-1 may provide a valuable indicator of neonatal condition immediately after birth, the clinical relevance of which needs to be further established.

Increasing Cesarean Section Rates in Very Low-Birth Weight Infants Effect on Outcome

Examination of a linked birth and death certificate file from Missouri revealed a remarkable increase in the use of cesarean section for very low—birth weight infants (500 to 1499 g) from 24% to 44% in the years 1980 to 1984. In the same years the rate for 1500- to 2499-g infants went from 21% to 26% and the rate for 2500- to 7000-g infants went from 14% to 18%. We studied first-day death rates in very low—birth weight infants as an indicator of potential benefit from this increase in cesarean sections. During the 5-year period first-day deaths averaged 10% and 22% in the cesarean and vaginal birth groups, respectively. This difference was explained almost entirely by deaths in the 500- to 740-g birth weight group, where the death rates were 33% and 59%, respectively. Although this difference remained statistically significant after adjustment for gestational age and other factors that differed between the groups, it was nullified by an excess of deaths in the succeeding 6 days of life. Overall, the odds of death in the first week in these infants weighing 500 to 749 g was 0.85 (95% confidence interval, 0.52 to 1.39) in the cesarean vs vaginal deliveries. We conclude that there is little evidence that the use of cesarean section for the delivery of very low—birth weight infants, independent of maternal or fetal compromise, improves overall survival. We were unable to find reasons to justify the sharp increase in the use of cesarean sections for these small infants. (JAMA. 1989;262:1475-1478)

Increasing cesarean section rates in very low-birth weight infants. Effect on outcome

Examination of a linked birth and death certificate file from Missouri revealed a remarkable increase in the use of cesarean section for very low—birth weight infants (500 to 1499 g) from 24% to 44% in the years 1980 to 1984. In the same years the rate for 1500- to 2499-g infants went from 21% to 26% and the rate for 2500- to 7000-g infants went from 14% to 18%. We studied first-day death rates in very low—birth weight infants as an indicator of potential benefit from this increase in cesarean sections. During the 5-year period first-day deaths averaged 10% and 22% in the cesarean and vaginal birth groups, respectively. This difference was explained almost entirely by deaths in the 500- to 740-g birth weight group, where the death rates were 33% and 59%, respectively. Although this difference remained statistically significant after adjustment for gestational age and other factors that differed between the groups, it was nullified by an excess of deaths in the succeeding 6 days of life. Overall, the odds of death in the first week in these infants weighing 500 to 749 g was 0.85 (95% confidence interval, 0.52 to 1.39) in the cesarean vs vaginal deliveries. We conclude that there is little evidence that the use of cesarean section for the delivery of very low—birth weight infants, independent of maternal or fetal compromise, improves overall survival. We were unable to find reasons to justify the sharp increase in the use of cesarean sections for these small infants. (JAMA. 1989;262:1475-1478)

Increasing Cesarean Section Rates in Very Low-Birth Weight Infants

Examination of a linked birth and death certificate file from Missouri revealed a remarkable increase in the use of cesarean section for very low—birth weight infants (500 to 1499 g) from 24% to 44% in the years 1980 to 1984. In the same years the rate for 1500- to 2499-g infants went from 21% to 26% and the rate for 2500- to 7000-g infants went from 14% to 18%. We studied first-day death rates in very low—birth weight infants as an indicator of potential benefit from this increase in cesarean sections. During the 5-year period first-day deaths averaged 10% and 22% in the cesarean and vaginal birth groups, respectively. This difference was explained almost entirely by deaths in the 500- to 740-g birth weight group, where the death rates were 33% and 59%, respectively. Although this difference remained statistically significant after adjustment for gestational age and other factors that differed between the groups, it was nullified by an excess of deaths in the succeeding 6 days of life. Overall, the odds of death in the first week in these infants weighing 500 to 749 g was 0.85 (95% confidence interval, 0.52 to 1.39) in the cesarean vs vaginal deliveries. We conclude that there is little evidence that the use of cesarean section for the delivery of very low—birth weight infants, independent of maternal or fetal compromise, improves overall survival. We were unable to find reasons to justify the sharp increase in the use of cesarean sections for these small infants. (JAMA. 1989;262:1475-1478)

Increasing Cesarean Section Rates in Very Low—Birth Weight Infants

Examination of a linked birth and death certificate file from Missouri revealed a remarkable increase in the use of cesarean section for very low-birth weight infants (500 to 1499 g) from 24% to 44% in the years 1980 to 1984. In the same years the rate for 1500- to 2499-g infants went from 21% to 26% and the rate for 2500- to 7000-g infants went from 14% to 18%. We studied first-day death rates in very low-birth weight infants as an indicator of potential benefit from this increase in cesarean sections. During the 5-year period first-day deaths averaged 10% and 22% in the cesarean and vaginal birth groups, respectively. This difference was explained almost entirely by deaths in the 500- to 740-g birth weight group, where the death rates were 33% and 59%, respectively. Although this difference remained statistically significant after adjustment for gestational age and other factors that differed between the groups, it was nullified by an excess of deaths in the succeeding 6 days of life. Overall, the odds of death in the first week in these infants weighing 500 to 749 g was 0.85 (95% confidence interval, 0.52 to 1.39) in the cesarean vs vaginal deliveries. We conclude that there is little evidence that the use of cesarean section for the delivery of very low-birth weight infants, independent of maternal or fetal compromise, improves overall survival. We were unable to find reasons to justify the sharp increase in the use of cesarean sections for these small infants.