Cesarean Section on Request at 39 Weeks: Impact on Shoulder Dystocia, Fetal Trauma, Neonatal Encephalopathy, and Intrauterine Fetal Demise
Section snippets
Shoulder Dystocia
For decades clinicians have struggled with the issue of shoulder dystocia and our general inability to find reliable predictors before delivery and the actual emergent event of shoulder dystocia. Among the risk factors that have received greatest attention are fetal macrosomia, maternal diabetes, maternal obesity, and the use of vacuum or forceps to achieve operative vaginal delivery.
Herbst and associates5 conducted a cost-effective analysis for the treatment of suspected fetal macrosomia and
Fetal Trauma
The majority of fetal trauma, whether sustained during vaginal delivery or cesarean section, will be associated with difficulties in the delivery process. Table 5 is a summary from recent literature of the types of trauma that have been associated with vaginal delivery. These injuries include, but are not limited to, laryngeal rupture, thoracic spinal cord injury, facial nerve palsy, and fractured humerus. In the majority of these cases, delivery occurred with singleton infants in vertex
Neonatal Encephalopathy and Permanent Neurologic Injury
Neonatal encephalopathy is a clinically defined syndrome of disturbed neurologic function in the infant at or near term (≥34 weeks) that occurs in the first week after birth. Neonatal encephalopathy is manifested by difficulty with initiating and maintaining respirations, depression of tone and reflexes, altered level of consciousness, and often seizures.27 The differential diagnosis of neonatal encephalopathy is large and the causes are heterogeneous. The International Consensus Conference28
Intrauterine Fetal Demise
In the United States, stillbirth occurs in nearly 1% (7 per 1000) of all births, and in the year 2000, there were nearly 27,000 stillbirths.31, 32 Currently, the U.S. stillbirth rate equals the mortality due to prematurity and SIDS combined. Additionally, the stillbirth rate equaled the number of infant deaths in the U.S. in 1998, with 28,371 infant deaths and 26,702 fetal deaths.32
Copper and associates33 have reported on the percentage of live births and stillbirths per week of gestational
Conclusion
Cesarean delivery performed on all women at 39 weeks would substantially reduce the occurrence of both transient and permanent brachial plexus injury, other forms of substantial physical trauma to the fetus, neonatal encephalopathy, and, in some instances, long-term neurologic impairment, intrapartum death, and intrauterine fetal demise beyond 39 weeks. What is unknown is the response that women will have when given this information and the degree to which it will impact their decision making.
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