Neonatal adverse outcome of elective caesarean section before 39 weeks of gestation

Francisco, Rossana Pulcineli Vieira; Zugaib, Marcelo

doi:10.1016/j.ramb.2013.01.002

EDITORIAL

Department of Obstetrics and Gynecology, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil

Corresponding author at

Elective cesarean sections, which are those not required by any clinical or obstetrical indication, are significantly increasing in all countries. The main reason for this increase is the possibility to schedule the birth, which, many times, is deemed convenient for the pregnant women and their doctors. The ethical and medical aspects of elective cesarean sections constitute a controversial and very discussed subject in the medical literature. However, little attention has been paid to the disturbing fact that these elective cesarean sections are been performed at increasingly early gestational ages.

In England, during the year 2000, 49% of elective cesarean sections were performed before the 39^th week of pregnancy. High rates (36.5%) were also described in the United States in 2002. The practice of elective cesarean sections at gestational ages between the 37^th and 38^th weeks is based on the justification that prematurity is defined as birth before the 37^th week and, therefore, it should be safe to end the pregnancy after this gestational age. Another advantage reported is the reduction in the risk, even after scheduling the birth, of patients going into labor and thus having to reformulate their plans. It must also be considered that when asking women about what gestational age they deem safe for birth, over 50% believed that it is between the 34^th and the 36^th week of pregnancy, which justifies the ease with which patients accept the early birth, and even the anxiety observed in pregnant women during the last weeks of pregnancy.¹

Elective cesarean section in the 37^th or 38^th week of pregnancy, although frequent in the medical practice, is not supported by the medical literature, which unanimously accepts that elective cesarean sections should be performed after the 39^th week of pregnancy.^2,3 This recommendation is based on the analysis of adverse neonatal outcomes in patients submitted to elective cesarean sections between the 37^th and the 39^th week of pregnancy. It can be noted that adverse neonatal outcomes are more frequent in elective cesarean sections at the 37^th week (10% to 17.8%) than after the 39^th week (1.5% to 4.6%). Among adverse neonatal outcomes, we have found situations ranging from obviously more serious conditions, such as hospitalization in neonatal intensive care unit, sepsis, and cardiorespiratory arrest, to conditions deemed mild, as hypoglycemia during the neonatal period and hospitalization for more than five days.^4,5

However, it is important to consider that we are addressing neonatal complications occurring solely and exclusively as a result of deliberate anticipation of birth, with no obstetrical indication, which will cause these children to face risk situations during their life due to a clearly iatrogenic basis.

Healthcare costs (whether public or supplementary), which will add totally unnecessary costs to this procedure, should also be analyzed. It is important to mention that some studies have indicated as more frequent maternal characteristics, in the group of patients submitted to elective cesarean sections before 39 weeks: higher average maternal age, lower body mass index, white skin color, married, and use of supplementary health plans.⁵ This fact makes it clear that this subject is not restricted to lower social classes or to public healthcare, and that it may be even more accentuated in patients with better social and economic situations.

Coupled with these facts, we also have to address the emotional damage to pregnant women and their families of the intensive care unit stay of such an expected child, sometimes with significant respiratory disorders and for a long period.

Elective cesarean sections at term (after 37 weeks), but before the 39^th week, are a worldwide concern. Some countries have been investing in the awareness of the medical professionals and pregnant women to prevent these procedures from being performed, unnecessarily exposing newborns to complications and to the risk of presenting sequelae over the long term, and they have been able to reduce the rate to less than 5% of cesarean sections performed between the 37^th and 39^th week of pregnancy.

Thus, this is a reflection on how iatrogenic it can be to indicate an elective cesarean section at term (after 37 weeks), but before 39 weeks of pregnancy, and on how we can change this situation with simple attitudes, by informing medical professionals and pregnant women about the risks of early birth.

REFERENCES

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