Immediate versus deferred delivery of the preterm baby with suspected fetal compromise for improving outcomes
Editorial Group: Cochrane Pregnancy and Childbirth Group
Published Online: 11 JUL 2012
Assessed as up-to-date: 9 MAR 2012
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Stock SJ, Bricker L, Norman JE. Immediate versus deferred delivery of the preterm baby with suspected fetal compromise for improving outcomes. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD008968. DOI: 10.1002/14651858.CD008968.pub2.
- Publication Status: New
- Published Online: 11 JUL 2012
Immediate delivery of the preterm fetus with suspected compromise may decrease the risk of damage due to intrauterine hypoxia. However, it may also increase the risks of prematurity.
To assess the effects of immediate versus deferred delivery of preterm babies with suspected fetal compromise on neonatal, maternal and long-term outcomes.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 February 2012).
Randomised trials comparing a policy of immediate delivery with deferred delivery or expectant management in preterm fetuses with suspected in utero compromise. Quasi-randomised trials and trials employing a cluster-randomised design were eligible for inclusion but none were identified.
Data collection and analysis
Two review authors independently evaluated trials for inclusion into the review. Two review authors assessed trial quality and extracted data. Data were checked for accuracy.
We included one trial of 548 women (588 babies) in the review. There was no difference in the primary outcomes of extended perinatal mortality (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.67 to 2.04) or the composite outcome of death or disability at or after two years (RR 1.22, 95% CI 0.85 to 1.75) with immediate delivery compared to deferred delivery. More babies in the immediate delivery group were ventilated for more than 24 hours (RR 1.54, 95% CI 1.20 to 1.97). There were no differences between the immediate delivery and deferred delivery groups in any other individual neonatal morbidity or markers of neonatal morbidity (cord pH less than 7.00, Apgar less than seven at five minutes, convulsions, interventricular haemorrhage or germinal matrix haemorrhage, necrotising enterocolitis and periventricular leucomalacia or ventriculomegaly).
More children in the immediate delivery group had cerebral palsy at or after two years of age (RR 5.88, 95% CI 1.33 to 26.02). There were, however, no differences in neurodevelopment impairment at or after two years (RR 1.72, 95% CI 0.86 to 3.41) or death or disability in childhood (six to 13 years of age) (RR 0.82, 95% CI 0.48 to 1.40). More women in the immediate delivery group had caesarean delivery than in the deferred delivery group (RR 1.15, 95% CI 1.07 to 1.24). Data were not available on any other maternal outcomes.
Currently there is insufficient evidence on the benefits and harms of immediate delivery compared with deferred delivery in cases of suspected fetal compromise at preterm gestations to make firm recommendations to guide clinical practice. Where there is uncertainty whether or not to deliver a preterm fetus with suspected fetal compromise, there seems to be no benefit to immediate delivery. Deferring delivery until test results worsen or increasing gestation favours delivery may improve the outcomes for mother and baby. More research is needed to guide clinical practice.
Plain language summary
Immediate or deferred delivery of the preterm baby with suspected fetal compromise for improving outcomes
When there is concern that a baby in the womb may not be receiving enough oxygen or nutrients, the choice is to deliver the baby immediately following a course of steroids to help the baby’s lungs to mature or to wait as long as is thought to be safe. Waiting allows the baby to develop as much as possible and decreases the risks associated with prematurity. Immaturity of the newborn can lead to respiratory distress, hypothermia (reduced body temperature), low blood sugar levels, infection and jaundice. Remaining in the womb may mean the baby experiences damage of vital organs from the lack of oxygen. The aim of this review was to assess which management option was better for mothers and babies.
We included one randomised study that involved 548 pregnant women (and 588 babies) with pregnancies between 24 and 36 weeks' gestation. The study was performed in 13 countries, between 1993 and 2001. Women were included if their doctor was concerned about the developing baby but unsure if immediate delivery was indicated. The women were randomly allocated to immediate delivery or delivery when the doctor considered that it was necessary.
For preterm babies with suspected fetal compromise and uncertainty about whether to deliver or not, there appears to be no benefit to immediate delivery. There was no difference in death or disability at two years of age between the groups. More women in the immediate delivery group were delivered by caesarean section and more babies delivered immediately required mechanical ventilation for longer than 24 hours. The number of infants with cerebral palsy at two years of age was also higher in the immediate delivery group but there was no differences in neurodevelopment impairment at or after two years, or death or disability in childhood (six to 13 years of age). Deferred delivery may be preferable, but further studies need to be performed to confirm these findings ant to determine any differences neonatal deaths. The difference in the median time between randomisation and delivery in the two groups was four days.