Shinohara 2020
Shinohara 2020
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contractions before elective caesarean
section and transient tachypnoea of the
newborn: a retrospective cohort study
Satoshi Shinohara , Atsuhito Amemiya, Motoi Takizawa
appears to be the lack of consensus on the definition contraction, is typically used to assess fetal well-being. In
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of labour onset between these studies and worldwide.19 this study, CTG data were recorded using an actocardio-
Furthermore, the different definitions of labour onset are graph (Toitu MT-516GE; Tofa Medical, Malvern, Penn-
based on various features, including cervical dilatation, sylvania). The prepregnancy body mass index (BMI) was
cervical effacement and uterine contractions.19 There- calculated according to the WHO standard (body weight/
fore, these studies are still open for further consideration. height squared (kg/m2)). Maternal weight gain during
Given the ambiguity surrounding the onset of labour, pregnancy was calculated by subtracting the patient’s
we examined the relationship between the presence of prepregnancy body weight from her body weight at the
uterine contractions before caesarean section alone and last prenatal visit before delivery. We defined SGA as a
TTN rather than considering all features of the onset of weight below the 10th percentile in each gestational
labour. Furthermore, no study to date has used the pres- week.22 The diagnosis of GDM was made if there was at
ence of uterine contractions to identify newborns at risk least one abnormal plasma glucose value (≥92, 180 and
of developing TTN. Therefore, we aimed to examine the 153 mg/dL for fasting, 1-hour and 2-hour plasma glucose
association between the presence of uterine contractions concentration, respectively) after a 75 g oral glucose toler-
before an elective caesarean section and TTN. ance test.23
Neonatal asphyxia was defined as an Apgar score
remaining less than 7 at 5 min after birth or as an arterial
Methods blood pH of less than 7.00.24 A diagnosis of TTN, which
Study design was the outcome of interest in this study, required each of
We performed a retrospective observational cohort study the following: respiratory rate >60 breaths/min, constant
of women who underwent an elective caesarean section tachypnoea for ≥12 hours, prominent central pulmonary
with spinal and epidural anaesthesia between January vessels or thickened interlobar fissures on a chest X-ray
2011 and May 2019 at the National Hospital Organi- and exclusion of other causes of respiratory distress, such
zation Kofu National Hospital, which is a community as surfactant deficiency, pneumonia, meconium aspira-
hospital. We excluded women with multiple pregnan- tion, congenital heart disease or metabolic disorder.25 A
cies, missing data and those who underwent an elective neonatologist diagnosed TTN based on the above diag-
caesarean section before a term delivery. In addition, nostic criteria in the first few hours after a baby was born.
we excluded cases in which the infant had neonatal Moreover, when the neonatologist diagnosed TTN, all
asphyxia. The Human Subjects Review Committee of the infants were treated in the neonatal intensive care unit.
National Hospital Organization Kofu National Hospital
reviewed and approved the study protocol and waived Statistical analyses
the need for informed consent because of the retrospec- The Mann-Whitney U test and χ2 test (or Fisher’s exact test
tive study design. However, patients were provided the when the expected frequency was <5) were used to eval-
opportunity to refuse the usage of their data through uate the effects of potential confounding factors of TTN.
the hospital’s website. All procedures were performed in The Mann-Whitney U test was used to analyse continuous
accordance with the 1964 Helsinki Declaration and its variables such as maternal age, and the χ2 test (or Fisher’s
later amendments. exact test when the expected frequency was <5) was used
for categorical variables such as incidence of obstetric
Data collection complications. A multiple logistic regression model was
We collected obstetric data from medical and operative used to identify the variables significantly associated with
records. We recorded maternal age, parity, gestational TTN. The logistic regression models were adjusted by
age at delivery, prepregnancy weight status and maternal uterine contraction, GDM, SGA infants, infant sex and
weight gain. Additionally, we assessed the presence of gestational age at delivery. All analyses were performed
gestational diabetes mellitus (GDM), small for gesta- using the Bell Curve for Excel (Social Survey Research
tional age (SGA), infant sex and neonatal asphyxia. Information, Tokyo, Japan) and IBM SPSS Statistics for
These potential confounding factors have been previ- Windows V.25. The significance level was set at p<0.05.
ously described as TTN risk factors.13 20 21 During the
study period, 523 women underwent elective caesarean Patient and public involvement
section. A total of 59 (missing data, n=12; twin pregnancy, Patients were not invited to comment on the study design
n=38; neonatal asphyxia, n=2; general anaesthesia, n=1; and were not consulted to develop patient- relevant
elective caesarean section before term delivery, n=6) outcomes or interpret the results.
were excluded. Cases of neonatal asphyxia were excluded
because this diagnosis was statistically underrepresented
in our study sample. Results
The women were grouped according to the presence A total of 464 women were considered eligible for inclu-
or absence of uterine contractions on a 40 min cardioto- sion in this study. The mean maternal age was 32.8±5.1
cogram (CTG) obtained within 6 hours before caesarean years, and the mean maternal prepregnancy BMI was
section. CTG, which records fetal heart rate and uterine 21.7±3.9 kg/m2, with 124 (26.7%) nulliparous women,
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Table 1 Clinical characteristics of the groups with and without uterine contractions
Variable* Uterine contraction (−) (n=178) Uterine contraction (+) (n=286) P value
Maternal age, years 33.0±5.2 32.7±5.0 0.49
Nulliparity 45 (25.3) 79 (27.6) 0.58
Repeat caesarean section 119 (66.9) 189 (65.0) 0.86
2
Prepregnancy BMI, kg/m 22.1±3.5 21.4±4.1 0.005
Birth weight, g 2839±320 2868±345 0.41
GDM 11 (6.2) 19 (6.6) 0.84
SGA 14 (7.9) 20 (7.0) 0.73
Male infant 90 (50.5) 144 (50.3) 0.96
TTN 25 (14.0) 21 (7.3) 0.02
Values are presented as the mean±SD or number (%).
*The Mann-Whitney U test was used to analyse continuous variables such as maternal age, and the χ2 test (or Fisher’s exact test when the
expected frequency was <5) was used for categorical variables such as incidence of obstetric complications.
BMI, body mass index; GDM, gestational diabetes mellitus; SGA, small for gestational age; TTN, transient tachypnoea of the newborn.
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Table 3 Crude and adjusted odds ratios of risk factors for TTN
Crude Adjusted
Variable TTN (n) Non-TTN (n) OR 95% CI OR 95% CI
Uterine contraction
Present 21 265 1.0 Reference 1.0 Reference
Absent 25 153 2.06 1.12 to 3.81 2.04 1.09 to 3.82
GDM
No 45 389 1.0 Reference 1.0 Reference
Yes 1 29 0.29 0.04 to 2.24 0.31 0.04 to 2.39
SGA
No 39 391 1.0 Reference 1.0 Reference
Yes 7 27 2.59 1.06 to 6.36 2.49 0.99 to 6.32
Male infant
No 18 212 1.0 Reference 1.0 Reference
Yes 28 206 1.60 0.86 to 2.98 1.55 0.82 to 2.93
Caesarean section
≥38 weeks 17 250 1.0 Reference 1.0 Reference
37 weeks 29 168 2.53 1.35 to 4.77 2.47 1.30 to 4.69
GDM, gestational diabetes mellitus; SGA, small for gestational age; TTN, transient tachypnoea of the newborn.
defined as six regular uterine contractions per hour.23 Previous reports indicate that a caesarean section at
Although the period without uterine contractions and 37 weeks is a major TTN risk factor,29 30 and our findings
that with five regular contractions per hour both occur support this conclusion. In our study, 16 (21.1%) of 76
before the onset of labour, it seems that the effect of each women with no uterine contractions who underwent a
period on stress hormone secretion is not the same. Our caesarean section at 37 weeks delivered an infant who
results demonstrate that the frequency of TTN is higher developed TTN (data not shown).
in patients with no uterine contractions than in patients Our study has limitations. First, this was a single-centre
with contractions. Although several studies evaluated the study, and it might be difficult to extrapolate our results
association between TTN and events occurring before to the general population. Therefore, a large-scale, multi-
labour and elective caesarean section,3 13 14 there is no centre, prospective cohort study is needed to confirm our
consensus on the definition of the onset of labour. For results in the general population. Second, we did not eval-
example, the onset of labour was described by Senturk et uate some potential TTN risk factors, including maternal
al26 as the onset of uterine contractions with labour pain asthma31 and low infant thyroid hormone level,32 and
and by Derbent et al27 as regular uterine contractions and there is the possibility that unmeasured confounders may
cervix effacement with dilatation of 2 cm or more. Mean- be associated with TTN in this study. Third, the generalis-
while, Tutdibi et al13 did not define the onset of labour in ability of our findings may be limited by the homogeneity
detail in their study. The diagnosis of labour onset may of this cohort, which only included Japanese women.
depend on the subjective opinion of the obstetrician or In conclusion, although studies with larger sample size
midwife. Objective indicators that can easily be deter- are required, we found that a lack of uterine contractions
mined are needed to identify TTN risk factors. This is before an elective caesarean section was significantly asso-
important because recently, in Japan, relatively few insti- ciated with TTN. Accurate risk stratification using a CTG
tutions allow vaginal birth after caesarean section, as they could assist in the management of infants who are at risk
are concerned about uterine rupture, with only approxi- of developing TTN.
mately 30% of institutions allowing planned vaginal birth
as an option after caesarean section.28 Antepartum CTG Acknowledgements We thank the study subjects for the use of their personal
can be routinely performed before elective caesarean data.
section without additional cost to easily and objectively Contributors SS and MT: data collection. SS: conception or design of the work. SS,
determine the presence or absence of uterine contrac- AA and MT: data analysis and interpretation; critical revision of the article. SS, AA
tions. As TTN is difficult to prevent, obstetricians, paedi- and MT: drafting of the article and final approval of the version to be published.
atricians and other medical professionals involved in an Funding The authors have not declared a specific grant for this research from any
elective caesarean section should be aware of the risk funding agency in the public, commercial or not-for-profit sectors.
factors of this complication and prepared to administer Competing interests None declared.
treatment. Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed. 14 Levine EM, Ghai V, Barton JJ, et al. Mode of delivery and risk of
BMJ Open: first published as 10.1136/bmjopen-2019-033154 on 16 March 2020. Downloaded from http://bmjopen.bmj.com/ on April 10, 2020 by guest. Protected by copyright.
respiratory diseases in newborns. Obstet Gynecol 2001;97:439–42.
Data availability statement All data relevant to the study are included in the 15 Maeda E, Ishihara O, Tomio J, et al. Cesarean section rates and local
article. resources for perinatal care in Japan: a nationwide ecological study
Open access This is an open access article distributed in accordance with the using the National database of health insurance claims. J Obstet
Gynaecol Res 2018;44:208–16.
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
16 Vaughan DA, Cleary BJ, Murphy DJ. Delivery outcomes for
permits others to distribute, remix, adapt, build upon this work non-commercially, nulliparous women at the extremes of maternal age - a cohort study.
and license their derivative works on different terms, provided the original work is BJOG 2014;121:261–8.
properly cited, appropriate credit is given, any changes made indicated, and the use 17 Oberg AS, VanderWeele TJ, Almqvist C, et al. Pregnancy
is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. complications following fertility treatment-disentangling the role of
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Satoshi Shinohara http://o rcid.org/0000-0003-3124-1141 caesarean section: a systematic review and meta-analysis of
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