Perinatal outcomes of term cesarean sections: A retrospective study in Northern Greece

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Research

HJOG 2025, 24 (2), 66-70| doi: 10.33574/hjog.0586

Dimitrios Papatheodorou1, Eirini Boureka2, Ioannis Tsakiridis2, Apostolos Mamopoulos2, Apostolos Athanasiadis2, Themistoklis Dagklis2

1 Laboratory of Hygiene and Epidemiology, Faculty of Medicine, University of Thessaly, Larissa, Greece
2 Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece

Correspondence: Ioannis Tsakiridis, Konstantinoupoleos 49, 54642, Thessaloniki, Greece, e-mail: iotsakir@gmail.com

Abstract

Introduction: Cesarian section rates are increasing globally, creating a possible risk factor for adverse neonatal outcomes. The present study aimed to investigate the optimal timing for elective cesarean section in pregnant women with a history of prior cesarean with regards to neonatal outcomes.

Material and Methods: A retrospective observational study (2017-2023) was conducted at the Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece. All cases of cesarean section, due to a previous cesarean, after 37+0 gestational weeks from and the neonatal outcomes were retrieved.

Results: In total, 829 cases of term cesarean sections were documented in women with a history of prior cesarean. From these, 51.1% delivered at 37+0 – 38+6 weeks, while 48.9% >39+0 weeks onwards. Neonates born >39+0 weeks showed higher 5-minute Apgar score (8.93 vs 8.89; p=0.03) and higher birthweight (3,402g vs 3,235g; p<0.001) compared to neonates born prior to 39 weeks. Additionally, there was an increased risk of cesarean section when labor was planned after 39 gestational weeks (p<0.001), due to onset of labor, initiation of contractions or rupture of membranes, posing a higher risk on adverse neonatal events.

Conclusion: Cesarean section >39+0 weeks was associated with better neonatal outcomes, so this policy should be adopted by all perinatal centers.

Keywords: Cesarean section, neonatal outcomes, elective, emergency

Introduction­

According to data from the Hellenic Statistical Authority (ELSTAT), in 2021, out of the 85,346 live births, 51,594 were performed via cesarean section (1); as a result, the cesarean section rate is approximately 60.5% (2). The optimal timing for performing a cesarean section has been a subject of research over the past decade, but international data remain limited and conflicting (3, 4). Most studies excluded multiple pregnancies and those with complications such as placenta previa, fetal anomalies, gestational diabetes, hypertensive disorders, fetal growth restriction, rupture of membranes and pre-existing maternal conditions; the most common indication for elective cesarean section was a history of previous cesarean (5).

Results from a large meta-analysis of observational studies demonstrated 95% higher risk of neonatal respiratory morbidity following elective cesarean compared to vaginal delivery (6). Additionally, when comparing term neonates, born at 39 gestational weeks, with either cesarean or vaginal birth, the cesarean group showed a 6-times higher risk of respiratory morbidity (6). Moreover, results from a multicenter study showed that elective cesarean section prior to 39 gestational weeks, resulted in an increased rate of maternal adverse outcomes (7).

The aim of this study was to investigate the possible benefits of elective cesarean section at 39 gestational weeks compared to 38 weeks, in terms of maternal and neonatal outcomes.

Material and methods

We conducted a single-center retrospective study during the period of 2017-2023 at the Third Department of Obstetrics and Gynecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece. The main inclusion criteria were pregnant women with a history of a prior cesarean, undergoing repeat cesarean section. More specifically, neonatal gender, weight, gestational week at delivery and parity were recorded.

Continuous variables were expressed as mean (standard deviation), while qualitative variables were expressed as absolute and relative frequencies. Independent samples Student’s t-tests were used for the comparison of mean values between groups. For the comparison of proportions Pearson’s or Fisher’s exact test was used. All reported p values are two-tailed. Statistical significance was set at p<0.05 and analyses were conducted using SPSS 26.0 statistical software.

Results

Demographics

In total, 829 neonates born between the 37th and 40th gestational week were included in the study, with 417 (50.3%) male and 412 (49.2%) female neonates. Regarding somatometric characteristics, the mean birthweight was calculated at 3,317g (SD=418.7g). Moreover, regarding parity, 763 (92%) women had one previous birth, 46 (5.5%) had two, 12 (1.4%) had three, 6 (0.7%) had four, and only 2 (0.1%) women had a history of five and six previous births, respectively.

From the total of 829 neonates 38 (4.6%) of them were admitted to the neonatal intensive care unit (NICU). Moreover, regarding the first neonatal evaluation after birth, the mean Apgar score was 7.9 (SD=0.5) in the 1st minute and 8.9 (SD= 0.4) in the 5th minute (Table 1).

As for the indication for cesarean, in 651 (78.5%) of cases the timing of labor was predetermined, whereas 52 (6.3%) presented with onset of labor, 56 (6.8%) with contractions, 57 (6.9%) with rupture of membranes, 5 (0.6%) with vaginal bleeding and 3 (0.4%) due to maternal COVID-19 infection.

Neonates were classified in two groups based on gestational week at delivery; group 1 consisted of 424 (51.1%) that were born between 37+0 and 38+6 weeks, whereas group 2 consisted of 405 (48.9%) that were delivered >39+0 weeks. Neonatal birthweight and Apgar score was significantly different among the two studied groups. More specifically, group 2 neonates presented with higher birthweight compared to the ones from group 1. Moreover, group 2 neonates presented with a higher 5-minute Apgar score, whereas there was no significant difference in 1-minute Apgar score (Table 2).

The indications for delivery were significantly different between the two groups. In group 2, 359 (88.6%) of neonates were born via elective cesarean section, whereas the rate of elective cesarean sections in group 1 was 68.9% (n=289) (Table 3).

Discussion

This study showed that neonates born via elective cesarean section after the 39th gestational week exhibited higher birthweight and a higher 5-minute Apgar score, indicating a better neonatal condition. Our findings align with results from other similar studies, which suggested that the birth of neonates prior to the 39th week correlated with lower Apgar scores, higher rates of transient tachypnea of the neonates, respiratory distress syndrome and NICU admission (6-8).

Moreover, our study showed that elective cesarean after 39 gestational weeks in women with a history of prior cesarean section entails a higher risk of emergency cesarean section at an earlier gestational age due to onset of labor, initiation of contractions or rupture of membranes, posing a higher risk of adverse neonatal events. According to a multi-center retrospective study, emergency cesarean section has been associated with a higher risk of adverse neonatal outcomes, such as NICU admission, lower Apgar scores and lower birthweight (8). However, this may be attributed to the earlier gestational age at which the cesarean section is performed rather than the intervention itself (9-11).

Cesarean section rates have been increased dramatically during the past decades. Besides the undoubtful benefit it prevails to maternal and fetal/neonatal outcomes, when indicated, the increasing number of cesarean sections performed is posing as a global socioeconomic burden. Additionally, the optimal timing of cesarean is of paramount importance with regards to neonatal outcomes. In conclusion it seems that women with a history of prior cesarean sections should be treated individually. Additionally, early identification of women eligible for trial of labor after cesarean would be of significant importance, as literature supports the benefits of vaginal delivery over elective or emergency cesarean in neonatal and maternal health.

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