Correspondence

Timing of Elective Repeat Cesarean Delivery at Term

N Engl J Med 2009; 360:1570-1571April 9, 2009

Article

To the Editor:

Tita et al. (Jan. 8 issue) suggest that delaying elective repeat cesarean delivery until 39 weeks of gestation will decrease the incidence of neonatal morbidity.1 However, delaying repeat cesarean delivery may have maternal and fetal consequences that are not addressed in their report. Between 38 and 39 weeks of gestation, approximately 10% of women go into spontaneous labor,2 with the result that planned cesarean deliveries are converted to emergency ones. The incidence of severe maternal morbidity is significantly higher among women undergoing emergency cesarean delivery than among those undergoing elective cesarean delivery.3 Complications may be greater among women after higher-order repeat cesarean deliveries4 and among older women.5 Therefore, the benefits of reducing neonatal morbidity from 11% at 38 weeks to 8% at 39 weeks, as reported by Tita et al., need to be weighed against the possible increase in the risks of severe maternal morbidity and perinatal mortality associated with delaying delivery.

Raed Salim, M.D.
Noah Zafran, M.D.
Eliezer Shalev, M.D.
Haemek Medical Center, 18101 Afula, Israel
salim_ra@clalit.org.il

5 References

1. 1

   Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009;360:111-120
   Full Text | Web of Science | Medline

2. 2

   Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. The national sentinel caesarean section audit report. London: RCOG Press, 2001.
   

3. 3

   Pallasmaa N, Ekblad U, Gissler M. Severe maternal morbidity and the mode of delivery. Acta Obstet Gynecol Scand 2008;87:662-668
   CrossRef | Web of Science | Medline

4. 4

   Sobande A, Eskandar M. Multiple repeat caesarean sections: complications and outcomes. J Obstet Gynaecol Can 2006;28:193-197
   Medline

5. 5

   Usta IM, Nassar AH. Advanced maternal age. Part I: obstetric complications. Am J Perinatol 2008;25:521-534
   CrossRef | Web of Science | Medline

Author/Editor Response

We disagree with the suggestion by Salim et al. that spontaneous labor preceding elective delivery is associated with severe maternal morbidity and perinatal mortality, which may outweigh the benefits that we reported of delaying delivery past 38 weeks of gestation. Women who have an otherwise elective (usually nonurgent) cesarean delivery after the onset of labor are commonly categorized among women undergoing “emergency” cesarean deliveries, the vast majority of which are due to failed labor or potential fetal compromise. Consequently, directly applying overall outcome estimates for this heterogeneous group to the small proportion of elective cesarean deliveries is inappropriate.1 As compared with prelabor cesarean delivery, elective cesarean delivery after the onset of labor is associated with improved neonatal outcomes.2 The risk of severe adverse maternal outcomes is very low and is not associated with labor preceding elective cesarean delivery, especially with a prior transverse lower uterine incision.3 Thus, since neonatal outcomes continue to improve and relatively few women deliver early because of spontaneous labor, planning elective cesarean delivery for 39 weeks of gestation is preferable.

Alan T.N. Tita, M.D., Ph.D.
University of Alabama at Birmingham, Birmingham, AL 35249
alan.tita@obgyn.uab.edu

Mark B. Landon, M.D.
Ohio State University, Columbus, OH 43210

Catherine Y. Spong, M.D.
Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892-2425

3 References

1. 1

   Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. The national sentinel caesarean section audit report. London: RCOG Press, 2001.
   

2. 2

   Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 2008;336:85-87
   CrossRef | Web of Science | Medline

3. 3

   Spong CY, Landon MB, Gilbert S, et al. Risk of uterine rupture and adverse perinatal outcome at term after cesarean delivery. Obstet Gynecol 2007;110:801-807
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Alan T. N. Tita, Yinglei Lai, Mark B. Landon, Catherine Y. Spong, Kenneth J. Leveno, Michael W. Varner, Steve N. Caritis, Paul J. Meis, Ronald J. Wapner, Yoram Sorokin, Alan M. Peaceman, Mary J. OʼSullivan, Baha M. Sibai, John M. Thorp, Susan M. Ramin, Brian M. Mercer. (2011) Timing of Elective Repeat Cesarean Delivery at Term and Maternal Perioperative Outcomes. Obstetrics & Gynecology 117:2, Part 1, 280-286
   CrossRef