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8 August 2012
Vaginal delivery as safe as cesarean for most preemies

Vaginal delivery for preterm babies presenting head first has a high rate of success with no difference in mortality compared to cesarean delivery, suggests a new study in the American Journal of Obstetrics and Gynecology.

"Selecting a route of delivery at less than 32 weeks' gestation is a difficult clinical decision given the high rate of infant mortality and morbidity as well as the maternal risks associated with cesarean delivery," says lead researcher Uma M. Reddy, of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. "For vertex-presenting [head first] fetuses less than 32 weeks' gestation, we saw no improvement in neonatal mortality with a planned cesarean delivery."

For the study, the researchers first categorized the indications for preterm delivery: preterm labor, preterm premature rupture of membranes (PPROM), or fetal/maternal issues such as preeclampsia, placental abruption, or severe maternal medical disease. Maternal or fetal indications were responsible for 46 percent of early preterm deliveries, PPROM for 38 percent, and preterm labor for 17 percent.

Preeclampsia and major congenital anomalies were the leading contributors to indicated early preterm births. The study then evaluated nearly 3,000 pregnancies between 24 weeks and 32 weeks eligible for either route of delivery. Attempted vaginal delivery was then compared to planned cesarean delivery.

The researchers found attempting vaginal delivery with vertex presentation at 24 to 28 weeks of gestation did not significantly affect neonatal mortality. More than 80 percent of the attempted vaginal births were successful. However, if the fetal presentation was breech, the majority of the deliveries were by planned cesarean delivery, and only 28 percent of attempted vaginal deliveries were successful.

Findings in the 28 to 32 weeks' gestation also differed by presentation. If the fetal presentation was vertex, the majority of attempted vaginal deliveries succeeded and there was no difference in the neonatal mortality rate compared with planned cesarean delivery. For breech-presenting fetuses, neonatal mortality was 6 percent for vaginal deliveries compared to 1.5 percent of the cesarean deliveries.

Reddy believes that the findings have direct clinical application and are crucial for counseling families about the benefit and risks of attempting vaginal delivery before full term.

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Source: American Journal of Obstetrics and Gynecology

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