Respiratory Morbidity in Neonates at or Near-Term in Relation to Mode of Delivery-A Retrospective Observational Study

Introduction: Antenatal corticosteroids are recommended by Royal College of Obstetrics and Gynaecology for caesarean section planned before thirty-eight plus six weeks gestation. However, these steroids are, not suggested for labour induced electively after thirty four weeks. Original Research Article Memon et al.; JPRI, 33(28B): 1-6, 2021; Article no.JPRI.68410


INTRODUCTION
Induction of labour the process of artificial stimulation to initiate labour. It occurs in up to 20% of pregnancies in the United Kingdom [1][2]. Different reasons for induction of labour have been archived in the literature. Maternal conditions included preeclampsia, cardiovascular or renal causes, while fetal reasons included intrauterine growth restriction, gestational diabetes, preterm rupture of membranes or post-maturity alone or in combinations [3]. Prior Corticosteroid injection to the expectant mother if preterm birth is anticipated is an important and most critical antenatal intervention available to enhance infant outcome. Betamethasone and dexamethasone are the most widely used corticosteroids. These are generally preferred to accelerate fetal lung maturation [4][5]. The Royal college of obstetrician and Gynaecologist UK (RCOG) and NICE guidelines (National Institute for Health and Care Excellence United Kingdom) recommends that antenatal corticosteroids should be administered to all women undergoing elective caesarean section before thirty-eight plus six weeks weeks of gestation [6][7]. The NICE guidelines do not recommend administration of corticosteroids to women having a planned vaginal delivery without fetal growth restriction after thirty-eight plus zero weeks [7]. However, the risks of neonatal morbidity at 35 weeks' gestation, regardless of mode of delivery, are similar to the risks associated with elective caesarean section at 37-38 weeks gestation for which corticosteroids are recommended. If antenatal corticosteroids are effective and costeffective in reducing neonatal morbidity after 34 weeks' gestation, then they should be offered to all women and not restricted to those having planned an elective caesarean section. However, if corticosteroids are ineffective or are not a costeffective intervention, these should not be offered after 34 weeks' gestation, irrespective of the mode of delivery planned.
The aim of this study is to assess the risk of respiratory morbidity in newborn babies as related to various planned methods of delivery conducted between thirty five and thirty eight weeks of gestation.

METHODOLOGY
This study observed the neonatal morbidity in 37961 pregnancies delivered between thirty five and thirty eight plus weeks gestation at the Royal Victoria Infirmary, Newcastle-upon-Tyne between June 2018 and December 2020. Electronic medical record database was the source of the patients' data from special care baby unit and maternity records. Data were analyzed using SPSS version 23.

DISCUSSION
It has been known since decades that administration of corticosteroids to a mother before preterm birth reduces the severity of lung disease of prematurity and other related complications in new-borns [8]. A Cochrane review of 21 studies showed benefits of treatment with single dose of corticosteroids in women with risk of preterm birth in reducing the risk of neonatal mortality by 31%., RDS by 44% and intraventricular haemorrhage by 46%. Antenatal corticosteroids have definitively shown to reduce neonatal morbidity and mortality in neonates born at or before thirty four weeks. The evidence that antenatal corticosteroids reduce neonatal morbidity after 34 weeks gestation is weak and there is no evidence that antenatal corticosteroids are a cost-effective intervention at this gestation age. The RCOG and NICE recommends that corticosteroids should be administered to all women undergoing elective caesarean section before thirty-eight plus six weeks gestation [6][7]. This is based on the results of studies which revealed that new born delivered by elective caesarean section at less than 39 +0 weeks of gestation had more chances of respiratory morbidity for which they required admission to the neonatal intensive care unit (NICU) [9][10][11][12]. An earlier cohort study mentioned that, compared with elective caesarean section, births at thirty nine weeks of gestation, at thirty seven weeks of gestation and at thirty eight weeks of gestation were related to an increased risk of of neonatal death and/ or respiratory complications; were trea ted for hypoglycaemia, early neonatal sepsis and admission to the NICU. The present study shows that the risk of admission to SCBU following elective caesarean section between 35 +0 and thirty-eight plus six weeks weeks (5.3%) is similar to the risk if labour was induced (6.5%) but corticosteroids not recommended. Our study also shown decreasing trend of neonatal intensive care admission (NICU) with each advancing week of gestation. This finding is in consistence with other study in the literature by Ghardey K et al. [13] that shown a 2-fold increased risk in primary outcome of respiratory morbidity among neonates delivered in near term as compared with those delivered at 39 weeks. Delivery between thirty-eight plus zero weeks and thirty-eight plus six weeks gestation is associated with significant neonatal morbidity, irrespective of the planned mode of delivery. The NICE guidelines do not recommend administration of corticosteroids to

CONCLUSION
Neonates delivered by elective delivery at thirtyfive to thirty eight weeks have high incidence of respiratory morbidity. Therefore, further research is mandated for role of prophylactic corticosteroids before elective induction of labour for better neonatal outcome.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
It is not applicable.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).