Elsevier

Seminars in Perinatology

Volume 30, Issue 5, October 2006, Pages 276-287
Seminars in Perinatology

Cesarean Section on Request at 39 Weeks: Impact on Shoulder Dystocia, Fetal Trauma, Neonatal Encephalopathy, and Intrauterine Fetal Demise

https://doi.org/10.1053/j.semperi.2006.07.009Get rights and content

Purpose

The purpose of this analysis was to determine the impact on specific forms of neonatal morbidity and mortality by allowing women to opt for delivery by elective cesarean section at 39 weeks of gestation (EGA). According to the National Vital Statistics Reports, over 70% of deliveries in the U.S. annually are at gestational ages ≥39 weeks EGA. Estimating that over 4 million deliveries occur annually in the United States, this would yield approximately 3 million pregnancies wherein the woman may exercise her choice for either primary or repeat cesarean section at 39 weeks EGA or at the point when labor is established.

Methods

A search was conducted using Ovid Medline spanning the past 10 years using the following key words: fetal trauma, shoulder dystocia, brachial plexus palsy, neonatal skull fracture, obstetrical trauma, traumatic delivery, intrauterine fetal demise, stillbirth, fetal demise, and neonatal encephalopathy. Using this search technique, over 2100 articles were identified. The abstracts were reviewed and pertinent articles were chosen for further consideration. The identified articles and their applicable references were obtained for inclusion in this review. Preference was given to publications on or after the year 2000 with the exception of classical or sentinel articles, which were included without regard to year of publication.

Results

Four major categories of neonatal morbidity and mortality are discussed:

Shoulder dystocia: Accepting that we do not have a successful method for the prediction or prevention of shoulder dystocia, the question becomes, “What is the chance that a baby will sustain a permanent brachial plexus injury at delivery?” Additionally, is there a significant protective effect of cesarean section in reducing the risk of such injury? Currently, the occurrence rate of brachial plexus palsy at the time of vaginal delivery ranges from 0.047% to 0.6% and for cesarean section from 0.0042% to 0.095%. Using a composite estimate of the risk of 0.15% for vaginal deliveries and applying it to the 3 million deliveries ≥39 weeks EGA, approximately 4500 cases of brachial plexus palsy would occur. If only 15% of these injuries were permanent, 675 permanent brachial plexus palsies would occur annually. If the risk of permanent injury is 1 in 10,000 as reported by Chauhan, 300 permanent brachial plexus palsies would occur annually in the United States. The range then for permanent brachial plexus injury that could be avoided with cesarean section on request would appear to vary between 1 in 5000 and 1 in 10,000 vaginal births.

Fetal trauma: The incidence of significant birth trauma varies from 0.2 to 1 to 2 per 1000 births. The use of sequential instruments, for example, vacuum followed by forceps or vice versa, is specifically associated with an unacceptably high injury rate. Intrapartum-related neonatal deaths of vertex singleton fetuses with birthweights >2500 g from traumatic cranial or cervical spine injury secondary to vacuum- or forceps-assisted vaginal delivery are still occurring. Overall, the frequency of significant fetal injury is significantly greater with vaginal delivery, especially operative vaginal delivery, than with cesarean section for the nonlaboring woman at 39 weeks EGA or near term when early labor has been established.

Neonatal encephalopathy: The prevalence of moderate to severe neonatal encephalopathy is 3.8/1000 term live births with a neonatal fatality rate of 9.1%. In 4% to 10% of cases, the etiology appears to be pure intrapartum hypoxia. Intrapartum hypoxia superimposed on antepartum risk factors may account for up to 25% of the moderate to severe encephalopathies, according to one cohort. A paradox in the data thus far is that infants born to nonlaboring women delivered by cesarean section had an 83% reduction in the occurrence of moderate or severe encephalopathy. Considering a prevalence of moderate or severe neonatal encephalopathy of 0.38% and applying it to the 3 million deliveries occurring at ≥39 weeks EGA in the United States annually, 11,400 cases of moderate to severe encephalopathy would occur. The rate of encephalopathy observed in infants delivered by cesarean section would yield approximately 1938 cases. This net difference in moderate to severe encephalopathy would represent 9462 cases annually in the United States that could be prevented with elective cesarean section. Although cesarean delivery may be protective for the development of neonatal encephalopathy, to date it has not proven to be protective of long-term neurologic injury in the form of cerebral palsy with or without mental retardation and/or seizure disorders.

Intrauterine fetal demise: Copper reported that the rate of stillbirth is consistent from 23 to 40 weeks EGA with about 5% of all stillbirths occurring at each week of gestation. Yudkin reported a rate of 0.6 stillbirths per 1000 live births from 33 to 39 weeks EGA. After 39 weeks EGA, a significant increase in the stillbirth rate was reported (1.9 per 1000 live births). Fretts reported on fetal deaths per 1000 live births from 37 to 41 weeks of gestational age, showing that the rate progressively increased from 1.3 to 4.6 with each week of gestation. It can be estimated that delivery at 39 weeks EGA would prevent 2 fetal deaths per 1000 living fetuses. This would translate into the prevention of as many as 6000 intrauterine fetal demises in the United States annually—an impact that far exceeds any other strategy implemented for stillbirth reduction thus far.

Conclusion

It is reasonable to inform the pregnant woman of the risk of each of the above categories, in addition to counseling her regarding the potential risks of a cesarean section for the current and any subsequent pregnancies. The clinician’s role should be to provide the best evidence-based counseling possible to the pregnant woman and to respect her autonomy and decision-making capabilities when considering route of delivery.

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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