53
Early Human Development, 23 (1990) 53-64 Elsevier Scientific Pnblishers Ireland Ltd. EHD 01070
Influence of elective cesarean section and breech delivery on neonatal neurological condition Grace OtamirP,
Ghan
Bergb, Torbjijrn Ledin”, Ingemar and Birgit Nilssonb
Leijon”
Departments of “Paediatrics and bObstetrics and Gynaecology, Faculty of Health Sciences, University Hospital, S-581 85 LinkCping (Sweden) (Received 7 February 1990; revision received 17 April 1990; accepted 20 April 1990)
Summary Fifty-three infants born after elective cesarean section (CS), and 28 infants born vaginally in breech presentation were compared with 45 full-term controls. A quantitative neurological assessment consisting of 3 1 items was performed on days 1, 2 and 5 after birth. A tonus score, an excitability score and the number of optimal responses were calculated. A follow-up examination was done at 6 months of age, with a standardized neurological and developmental examination. The results showed that infants born after elective CS in both vertex and breech presentation had significantly reduced number of optimal responses during the first five days after delivery, compared to controls. They were more hypotonic and less excitable than the control infants during the first 2 days. There were no significant differences in neurological results between infants born after CS with general or epidural anaesthesia. The infants born in vaginal breech presentation showed no differences neurologically as compared to the controls on the first day. On days 2 and 5, however, they were less excitable and showed a reduced number of optimal responses. There were few differences in neurological condition between the infants born after elective CS and the infants born vaginally in breech presentation. Growth, psychomotor development and neurological status at 6 months did not differ significantly between the three groups. Our findings indicate that infants born after elective CS and vaginal breech presentation have a delayed neurological adaptation during their first days of life. These differences did not affect the physical well-being of the infants, which showed normal growth, neurology and development at the follow-up at 6 months of age. full-term infants; cesarean section; vaginal breech; neurological function; psychomotor development. 0378-3782MV503.50 0 1990 Elsevier Scientific Publishers Ireland Ltd. Published and Printed in Ireland
54
Introduction For an increasing proportion of women, surgical delivery by cesarean section (CS) has become a part of the childbirth experience. In many industrialized countries the CS rate has been rising. In the U.S.A., for instance, there has been an increase from 14.1% in 1971 to 19.0% in 1984 [26]. In Western Europe, CS rates are lower than in the U.S.A., but have been following the same trend. The frequency of CS in Sweden was 10.7% in 1987 (Swedish National Birth Statistics). The frequency of breech presentation at term has been reported to be 3-4070 [ 14,251. The breech delivered neonate at full term has a higher risk of morbidity and a reduced size at birth [17-191. CS is often used as an alternative method to vaginal delivery in breech presentation, due to the higher risk of complications leading to asphyxia [ 11,23,25] and trauma [ l,S]. The effect on the fetus of CS per se is not completely known. It has previously been shown that newborns delivered by CS have an increased risk of disturbed respiratory adaptation [4,5,12,23,28], possibly due to lower neonatal catecholamine levels after elective CS than after vaginal delivery [ 10,131. The aim was to investigate whether elective CS and vaginal breech delivery at term had an influence on (i) neonatal neurological function and (ii) neurological and psychomotor development up to 6 months of age. Also, our aim was to compare the neonatal neurological status in neonates after CS, breech and vertex deliveries. Material and Methods The study was performed at the Departments of Paediatrics and Obstetrics/ Gynaecology at the University Hospital, Linkoping and at the Central Hospital, Motala, between February 1987 and December 1988. The total number of deliveries during this period was 4,120 at the Linkoping University Hospital and 1,760 at the Central Hospital, Motala. During this time 11.5% of all mothers were delivered by CS, 60% of them electively. Primiparae as well as multiparae who fulfilled the following criteria were included in the study. CS group
The CS group consisted of 53 mothers and their infants. Pregnant women with medical indications for elective CS were selected according to the following inclusion criteria provided they agreed to participate in the study:
(1) (2) (3) (4) (5)
(6)
Medically uneventful pregnancy, with gestational age confirmed by early ultrasound examination. Delivery at full-term age (after 37 completed weeks). Normal fetal growth and no suspicion of fetal disease. Single birth. Indications for CS being feto-pelvic disproportion, previous CS, placenta praevia or humanitarian (that is CS because of fear of vaginal child birth). No labour activity at the time of surgery.
55
Breech group Twenty-eight mothers and their infants, delivered after 37 completed weeks in breech presentation, were included during the same study period. All vaginal breech deliveries were eligible provided they fullfilled the following criteria: (l-4) (5) (6) (7)
See above for CS group. Adequate pelvic outlet, as judged by pelvimetry. No signs of dystocia. No signs of fetal distress during labour.
After delivery the parents gave their informed consent to participate in the study. Vertex group A control group of 45 healthy mothers and their infants, seen during the same period, were selected consecutively after delivery and partly matched following each CS mother, using the following criteria: (l-4) (5) (6) (7) (8) (9)
See above for CS group. Maternal age f 5 years of the CS mothers. Gestational age + 1 week of the CS mothers (all > 37 completed weeks). Vertex presentation without signs of fetal distress. No instrumental assistance during delivery. No analgesia with pethidine or morphine during delivery. Women who gave their consent were included in this study.
Maternal characteristics These are shown in Table I. There were no significant differences between the groups concerning maternal age, marital status, educational level, smoking habits and alcohol use during pregnancy. Obstetrical management Of 53 mothers operated by elective CS, 12 had breech presentation. The indication for CS was feto-pelvic disproportion in 32 cases, CS in previous pregnancy in 15 cases and placenta praevia in one case. In the remaining five cases the indication was humanitarian (fear of vaginal child birth). In the CS group 10 women were operated with general anaesthesia (GA) and 43 with epidural or spinal anaesthesia (EDA/ SA). Premeditation with 0.5 mg atropine was used in all cases. General anaesthesia with thiopental and pankuron as induction followed by fentanyl was used. In women receiving EDA/SA, bupivacaine was used as local anaesthetic. In the breech group four women were induced by amniotomy. Epidural anaesthesia (EDA) was used in two women and paracervical block (PCB) in four. Labour started spontaneously in 41 of the vertex control women. During the first stage of labour, three women received EDA analgesia and six women PCB, no one later than 3-4 h before delivery. Women who delivered vaginally (both vertex and breeches) received pudendal block during their second stage. Labour and delivery were normal in all
56 TABLE I Maternal characteristcs: parity, amount of bleeding at delivery and duration of days at the materity ward.
cs n = 53
Vaginal Breech n = 28
Primiparae
12 (23%)
11 (39%)
9 (20%)
Multiparae
41 (77%)
17 (61%)
36 (80%)
Bleeding, ml (mean f S.D.)
456 f 178
251 A 168
261 + 189
I***)
Vertex n = 45
I***I
Duration of days at maternity ward (mean f S.D.)
**P
Early Human Development, 23 (1990) 53-64 Elsevier Scientific Pnblishers Ireland Ltd. EHD 01070
Influence of elective cesarean section and breech delivery on neonatal neurological condition Grace OtamirP,
Ghan
Bergb, Torbjijrn Ledin”, Ingemar and Birgit Nilssonb
Leijon”
Departments of “Paediatrics and bObstetrics and Gynaecology, Faculty of Health Sciences, University Hospital, S-581 85 LinkCping (Sweden) (Received 7 February 1990; revision received 17 April 1990; accepted 20 April 1990)
Summary Fifty-three infants born after elective cesarean section (CS), and 28 infants born vaginally in breech presentation were compared with 45 full-term controls. A quantitative neurological assessment consisting of 3 1 items was performed on days 1, 2 and 5 after birth. A tonus score, an excitability score and the number of optimal responses were calculated. A follow-up examination was done at 6 months of age, with a standardized neurological and developmental examination. The results showed that infants born after elective CS in both vertex and breech presentation had significantly reduced number of optimal responses during the first five days after delivery, compared to controls. They were more hypotonic and less excitable than the control infants during the first 2 days. There were no significant differences in neurological results between infants born after CS with general or epidural anaesthesia. The infants born in vaginal breech presentation showed no differences neurologically as compared to the controls on the first day. On days 2 and 5, however, they were less excitable and showed a reduced number of optimal responses. There were few differences in neurological condition between the infants born after elective CS and the infants born vaginally in breech presentation. Growth, psychomotor development and neurological status at 6 months did not differ significantly between the three groups. Our findings indicate that infants born after elective CS and vaginal breech presentation have a delayed neurological adaptation during their first days of life. These differences did not affect the physical well-being of the infants, which showed normal growth, neurology and development at the follow-up at 6 months of age. full-term infants; cesarean section; vaginal breech; neurological function; psychomotor development. 0378-3782MV503.50 0 1990 Elsevier Scientific Publishers Ireland Ltd. Published and Printed in Ireland
54
Introduction For an increasing proportion of women, surgical delivery by cesarean section (CS) has become a part of the childbirth experience. In many industrialized countries the CS rate has been rising. In the U.S.A., for instance, there has been an increase from 14.1% in 1971 to 19.0% in 1984 [26]. In Western Europe, CS rates are lower than in the U.S.A., but have been following the same trend. The frequency of CS in Sweden was 10.7% in 1987 (Swedish National Birth Statistics). The frequency of breech presentation at term has been reported to be 3-4070 [ 14,251. The breech delivered neonate at full term has a higher risk of morbidity and a reduced size at birth [17-191. CS is often used as an alternative method to vaginal delivery in breech presentation, due to the higher risk of complications leading to asphyxia [ 11,23,25] and trauma [ l,S]. The effect on the fetus of CS per se is not completely known. It has previously been shown that newborns delivered by CS have an increased risk of disturbed respiratory adaptation [4,5,12,23,28], possibly due to lower neonatal catecholamine levels after elective CS than after vaginal delivery [ 10,131. The aim was to investigate whether elective CS and vaginal breech delivery at term had an influence on (i) neonatal neurological function and (ii) neurological and psychomotor development up to 6 months of age. Also, our aim was to compare the neonatal neurological status in neonates after CS, breech and vertex deliveries. Material and Methods The study was performed at the Departments of Paediatrics and Obstetrics/ Gynaecology at the University Hospital, Linkoping and at the Central Hospital, Motala, between February 1987 and December 1988. The total number of deliveries during this period was 4,120 at the Linkoping University Hospital and 1,760 at the Central Hospital, Motala. During this time 11.5% of all mothers were delivered by CS, 60% of them electively. Primiparae as well as multiparae who fulfilled the following criteria were included in the study. CS group
The CS group consisted of 53 mothers and their infants. Pregnant women with medical indications for elective CS were selected according to the following inclusion criteria provided they agreed to participate in the study:
(1) (2) (3) (4) (5)
(6)
Medically uneventful pregnancy, with gestational age confirmed by early ultrasound examination. Delivery at full-term age (after 37 completed weeks). Normal fetal growth and no suspicion of fetal disease. Single birth. Indications for CS being feto-pelvic disproportion, previous CS, placenta praevia or humanitarian (that is CS because of fear of vaginal child birth). No labour activity at the time of surgery.
55
Breech group Twenty-eight mothers and their infants, delivered after 37 completed weeks in breech presentation, were included during the same study period. All vaginal breech deliveries were eligible provided they fullfilled the following criteria: (l-4) (5) (6) (7)
See above for CS group. Adequate pelvic outlet, as judged by pelvimetry. No signs of dystocia. No signs of fetal distress during labour.
After delivery the parents gave their informed consent to participate in the study. Vertex group A control group of 45 healthy mothers and their infants, seen during the same period, were selected consecutively after delivery and partly matched following each CS mother, using the following criteria: (l-4) (5) (6) (7) (8) (9)
See above for CS group. Maternal age f 5 years of the CS mothers. Gestational age + 1 week of the CS mothers (all > 37 completed weeks). Vertex presentation without signs of fetal distress. No instrumental assistance during delivery. No analgesia with pethidine or morphine during delivery. Women who gave their consent were included in this study.
Maternal characteristics These are shown in Table I. There were no significant differences between the groups concerning maternal age, marital status, educational level, smoking habits and alcohol use during pregnancy. Obstetrical management Of 53 mothers operated by elective CS, 12 had breech presentation. The indication for CS was feto-pelvic disproportion in 32 cases, CS in previous pregnancy in 15 cases and placenta praevia in one case. In the remaining five cases the indication was humanitarian (fear of vaginal child birth). In the CS group 10 women were operated with general anaesthesia (GA) and 43 with epidural or spinal anaesthesia (EDA/ SA). Premeditation with 0.5 mg atropine was used in all cases. General anaesthesia with thiopental and pankuron as induction followed by fentanyl was used. In women receiving EDA/SA, bupivacaine was used as local anaesthetic. In the breech group four women were induced by amniotomy. Epidural anaesthesia (EDA) was used in two women and paracervical block (PCB) in four. Labour started spontaneously in 41 of the vertex control women. During the first stage of labour, three women received EDA analgesia and six women PCB, no one later than 3-4 h before delivery. Women who delivered vaginally (both vertex and breeches) received pudendal block during their second stage. Labour and delivery were normal in all
56 TABLE I Maternal characteristcs: parity, amount of bleeding at delivery and duration of days at the materity ward.
cs n = 53
Vaginal Breech n = 28
Primiparae
12 (23%)
11 (39%)
9 (20%)
Multiparae
41 (77%)
17 (61%)
36 (80%)
Bleeding, ml (mean f S.D.)
456 f 178
251 A 168
261 + 189
I***)
Vertex n = 45
I***I
Duration of days at maternity ward (mean f S.D.)
**P
