Abstract
Cesarean delivery is a common route of delivery before term, but the benefits or harms for preterm infants are still unknown. This review aimed to gather information on the current epidemiology of preterm cesarean delivery using data from international collaborations and on neonatal outcomes concerning the mode of delivery. Of note, 4 obstetrical scenarios were reviewed: preterm births with cephalic or noncephalic fetal presentations, preterm preeclampsia, and preterm birth of multiple pregnancies. In addition, cesarean delivery for preterm birth and its association with later child health was briefly discussed. In Europe, the highest cesarean delivery rates were reported in very preterm births (66%) and moderately preterm births (58%), with marked between-country variations. Among very preterm infants, international cesarean delivery rates averaged 70% at 28 to 31 weeks of gestation, with declining and more variable rates at lower gestational ages, especially at 22 and 23 weeks of gestation. In moderate preterm births (32-33 weeks of gestation) and late preterm births (34-36 weeks of gestation), country-specific cesarean delivery rates mirrored practice in the full-term population. In low-risk, singletons in cephalic position, primary cesarean delivery before term has been associated with a higher risk of neonatal respiratory morbidity than vaginal delivery, particularly among moderate-late preterm infants. However, preterm cesarean delivery for breech presentation (singleton and multiple pregnancies with the first fetus in noncephalic presentation) has been associated with lower neonatal mortality than vaginal delivery, particularly among very extremely preterm infants. The literature provided no clear and consistent support for the neonatal benefits of cesarean delivery vs a trial of induction of labor in preterm preeclampsia. The same was true for twin pregnancies, except for monoamniotic twin pregnancies that were recommended for primary cesarean delivery in moderately preterm gestations. There are associations between preterm cesarean delivery and adverse childhood health outcomes, but causality has not been established. With the exception of moderate and late preterm births, in which unnecessary, policy-dictated cesarean delivery could be reduced, there are usually strong medical indications for cesarean delivery in very or extremely preterm gestations. In such situations, the immediate benefits for the infant of increased chances of survival without severe neonatal morbidity should outweigh any long-term health issues. In conclusion, there is insufficient evidence to support routine delivery of preterm infants by cesarean delivery except for breech presentation, maternal or fetal emergencies, and monoamniotic twins.