The primary outcomes were neonatal respiratory morbidity, sepsis, feeding difficulties, neonatal intensive care unit (NICU) admission, and infant mortality.
The authors found no statistically significant increase in neonatal mortality in the early term induction group; however, even with the large numbers of pregnancies studied, given the rarity of such deaths, such a linkage cannot be entirely excluded. They also found no differences in respiratory morbidity, sepsis, or NICU admission in the early elective versus 39 to 40 week control group, although the former did have more feeding difficulties (OR 1.18; 99%CI: 1.02–1.36). However, when examining differences between nulliparous women and multiparous women without prior cesarean deliveries undergoing early elective induction, the latter group’s infants displayed higher NICU admission rates (OR 1.23; 99%CI: 1.06–1.42), and feeding difficulties (OR 1.28; 99%CI: 1.06–1.55). By contrast, infants delivered by early elective cesarean experienced a 66% increase in respiratory morbidity, 51% more NICU admissions, and 36% higher rate of feeding abnormalities as well as an increased risk of sepsis (OR of 1.13; 99%CI: 1.01–1.29) compared to those delivered at 39 to 40 weeks. Here again the infants of multiparous women without prior cesarean deliveries fared worse than infants of nulliparous women.
These findings suggest that the extent of neonatal morbidity accruing early elective induction of nulliparous women may be less than previously suspected. However, such inductions increase neonatal morbidity among multiparas. Clearly, early cesarean deliveries are associated with excess morbidity in both maternal groups. The authors state that “issues that surround the timing and reasons for delivery initiation are complicated and each pregnancy unique. This study cautions against a general avoidance of all elective early-term deliveries.”
We can be reasonably reassured that national quality assurance efforts aimed at reducing elective early term deliveries have not resulted in a dramatic increase in term stillbirth rates. However, the magnitude of the neonatal risks of elective early term delivery in nulliparous women, who are at greatest risk for subsequent stillbirth and obstetrical complications, may have been exaggerated by earlier studies. Moreover, there are real concerns that in our zeal to reduce truly “elective” early term deliveries, patients with bona fide medical or obstetrical indications for such early deliveries may be experiencing inappropriate and potentially harmful pregnancy prolongation.
On balance, I believe that non-medically indicated early term deliveries should be discouraged but it falls to the obstetrician’s art to constantly assess whether a patient with a complicated pregnancy is better of delivered.
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