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Zahedi-Spung LD, Raghuraman N, Macones GA, Cahill AG, Rosenbloom JI. Neonatal morbidity and mortality by mode of delivery in very preterm neonates. Am J Obstet Gynecol. 2021 Jul 28:S0002-9378(21)00827-9.

Background: The safest mode of delivery for very preterm infants is an ongoing topic of debate. There are many reasons for cesarean delivery (CD) in extremely preterm and very preterm infants, including labor, fetal distress, maternal indications, and malpresentation.

Objectives: This study aimed to determine whether CD is associated with significantly improved neonatal morbidity.

Study design: This study is a retrospective cohort study of all singleton pregnancies delivered at 22.0 – 29.0 weeks gestation between 2010 and 2015 admitted for preterm labor (PTL) or preterm premature rupture of membranes (PPROM), excluding neonates with a delivery weight ≤ 500 grams, multiple gestations, intrauterine fetal demise, and induction terminations. The primary outcome for the study was a neonatal morbidity composite (APGAR < 5 at 5 min, prolonged ventilation (>28 days), intraventricular hemorrhage, necrotizing enterocolitis, coagulopathy, discharged on home ventilator support, or discharged with enteric feeding tube). CD was performed for standard obstetric indications. Regression models were used adjusting for nulliparity, delivery year, and presentation at time of delivery to determine whether CD is associated with neonatal morbidity or neonatal death.

Results: There were 271 eligible deliveries, 128 cesarean deliveries and 143 vaginal deliveries. The CD group had fewer nulliparous patients and more fetuses that presented breech at time of delivery. Overall composite neonatal morbidity occurred in 202/271 (74.5%) of deliveries and mortality occurred in 7/271 (2.58%) of deliveries. When adjusting for nulliparity, delivery year, and fetal presentation at time of delivery, CD was associated decreased risk of death in the delivery room or within 24 hours of delivery (aRR 0.18, 95% CI 0.05, 0.63, p=0.03). CD was also associated with increased use of exogenous surfactant (aRR 1.20, 95% CI 1.05, 1.38, p=0.01) and bag mask ventilation (aRR 1.17, 95% CI 1.01, 1.37, p=0.03). and In a secondary analysis looking only at patients receiving a complete course of steroids, there were no differences in composite morbidity or mortality.

Conclusion: CD performed for standard obstetric indications in very preterm neonates is associated with a decreased risk of a death in the delivery room or within 24 hours of delivery but is not associated with improvement in morbidity or mortality overall.

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