European Journal of Obstetrics & Gynecology and Reproductive Biology
Full length articleDelivery mode and intraventricular hemorrhage risk in very-low-birth-weight infants: Observational data of the German Neonatal Network
Introduction
Significant progress in perinatal medicine over the last decades resulted in a remarkable decrease in neonatal morbidity and mortality [1]. It is still a matter of debate, though, whether mode of delivery affects the outcome of very-low-birth-weight infants (VLBWI).
Obstetricians are often in the uncomfortable position to decide how to deliver a preterm infant – vaginally or by cesarean section (CS). One of the main problems is that to date sufficient data of prospective randomized controlled trials (RCT) are not available and recommendations for clinical practice were taken from retrospective analyses.
For abnormal presentation or emergency situations, cesarean section is the recommended route of delivery for the infant [2], [3], [4]. Optimal mode for delivery of a preterm infant in vertex presentation remains controversial [5], [6], [7], [8], [9], [10], [11], [12] and data about neonatal outcome are inconsistent [5], [13], [14]. Some investigators showed no survival advantage [8], [14], [15], [16] or significant influence on neurodevelopmental outcome in extremely VLBWI [17], [18], [19] for planned CS. However, an increasing cesarean section rate of premature infants at low gestational ages [20], [21] may be explained by publications showing a better outcome after planned CS [5], [11], [22], [23]. In addition, some authors found cesarean section to reduce the risk of developing severe grades of IVH in premature infants <28 weeks [24], [25], [26].
Planned cesarean section seems to reduce postnatal risks for premature infants delivered at an early gestational age, but increases the risks for late preterm infants, causing a higher rate of mortality, morbidity and respiratory complications [26], [27].
In the German Neonatal Network we therefore investigated the influence of antenatal factors and mode of delivery on neonatal outcome in singleton birth infants born after preterm labor. Our aim was to use a large population-based cohort of VLBWI to derive a cut-off point (gestational week) below which planned CS is more likely to reduce morbidity in premature infants than vaginal delivery (VD).
Section snippets
Cohort
The German Neonatal Network (GNN) is an ongoing population-based cohort study enrolling VLBWI in Germany. Data are obtained from 54 participating neonatal intensive care units (NICU) in Germany. Approval by the local ethic committee for research in human subjects of the University of Luebeck (file number 08-022) and by the local ethic committees of all participating centres has been given. After written informed consent is obtained from the parents or legal guardians, infants <1500 g birth
Results
The entire cohort of the GNN consisted of 11564 preterm infants born at 22 0/7–36 6/7 weeks gestation with a birth weight <1500 g. After exclusion of multiples and infants born due to HELLP syndrome and preeclampsia, data of 2203 VLBW infants were eligible for analysis of antenatal factors and 2201 for postnatal factors (see Fig. 1).
VLBWI were grouped into one of the three delivery modes: 1381 (62.7%) infants were delivered via planned cesarean section, 632 (28.6%) via vaginal birth and 190
Discussion
We conducted a large observational cohort study of preterm infants <1500 g birth weight and with 22 0/7–36 6/7 weeks gestation in Germany to address the impact of mode of delivery on deleterious outcome such as IVH.
Although planned CS is the standard delivery mode for preterm infants in Germany, a ‘cut-off’-gestational age when vaginal delivery in women presenting with premature labor improves the neonatal outcome is unknown. We showed that elective cesarean deliveries in preterm infants <30
Competing interests
None to declare.
Acknowledgments
The authors would like to thank all nurses, doctors and participating NICUs for their support and especially all participating infants and their parents.
References (37)
- et al.
Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial
Lancet
(2000) Method of delivery for the preterm infant
BJOG: Int J Obstet Gynecol
(2003)- et al.
Method of delivery and neonatal outcome in very low-birthweight vertex-presenting fetuses
Am J Obstet Gynecol
(2008) - et al.
Does labor influence neonatal and neurodevelopmental outcomes of extremely-low-birth-weight infants who are born by cesarean delivery?
Am J Obstet Gynecol
(2003) - et al.
Are active labour and mode of delivery still a challenge for extremely low birth weight infants? Experience at a tertiary care hospital
Eur J Obstet Gynecol Reprod Biol
(2009) - et al.
The NICHD neonatal research network: changes in practice and outcomes during the first 15 years
Semin Perinatol
(2003) - et al.
Obstetric determinants of neonatal survival: influence of willingness to perform cesarean delivery on survival of extremely low-birth-weight infants. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units
Am J Obstet Gynecol
(1997) - et al.
Neonatal mortality by attempted route of delivery in early preterm birth
Am J Obstet Gynecol
(2012) - et al.
Factors influencing neonatal outcomes in the very-low-birth-weight fetus
Am J Obstet Gynecol
(1994) - et al.
Variability in caesarean section rates for very preterm births at 28–31 weeks of gestation in 10 European regions: results of the MOSAIC project
Eur J Obstet Gynecol
(2010)
Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1, 500 gm
J Pediatr Mosby
Trends in care practices, morbidity, and mortality of extremely preterm neonates, 1993–2012
JAMA
Neonatal outcomes of preterm infants in breech presentation according to mode of birth in Canadian NICUs
Postgrad Med J
Vaginal delivery versus caesarean section in preterm breech delivery: a systematic review
Eur J Obstet Gynecol Reprod Biol.
Impact of cesarean section on neonatal mortality rates among very preterm infants in the United States, 2000–2003
Pediatrics
The effect of type of delivery on neonatal outcome in singleton infants of birth weight of 1,000 g or less
JAMA
The relationship between delivery mode and mortality in very low birthweight singleton vertex-presenting infants
BJOG: Int J Obstet Gynecol
Proactive management promotes outcome in extremely preterm infants: a population-based comparison of two perinatal management strategies
Pediatrics
Cited by (54)
Aberrant gut-microbiota-immune-brain axis development in premature neonates with brain damage
2021, Cell Host and MicrobeCitation Excerpt :In premature infants, prescription of broad-spectrum antibiotics (Zwittink et al., 2017) and mode of delivery (Aguilar-Lopez et al., 2021) have been reported to affect gut-microbiota development. Cesarean (C)-sections are generally considered to be the safer delivery method for extremely premature infants, given the increased risk for respiratory distress during spontaneous delivery which can lead to brain injuries (Humberg et al., 2017). This agrees with our observation of heightened incidence for severe brain injury in spontaneously delivered premature infants (Table 1).
Umbilical Cord Milking vs Delayed Cord Clamping and Associations with In-Hospital Outcomes among Extremely Premature Infants
2021, Journal of PediatricsCitation Excerpt :In our stratified analysis, the presence of chorioamnionitis did not affect the exposure and primary composite outcome relationship. Previous studies have also reported that infants born via vaginal delivery are at increased risk of IVH.38 A similar stratified analysis found that the mode of delivery had no effect on the relationship between placental transfusion and the primary composite outcome.
Vaginal birth—Advantages and disadvantages for mother and child
2024, GynakologieaEEG in the first 3 days after extremely preterm delivery relates to neurodevelopmental outcomes
2024, Journal of Perinatology