Caesarean section is one of the most frequently performed obstetric procedures worldwide, and its rate has increased substantially in many countries. Rates of caesarean delivery vary considerably between regions, with high rates reported in several Asian, European and Latin American countries [1,2]. In India, increasing access to institutional delivery and changes in obstetric practice have also contributed to increasing caesarean delivery rates. Although caesarean section is essential when medically indicated, unnecessary or elective caesarean delivery may expose mothers and neonates to avoidable risks. Neonates delivered by elective caesarean section have been reported to have increased respiratory morbidity and a greater requirement for NICU admission, particularly when delivery occurs before complete fetal pulmonary maturity [3-5]. Absence of labour may also delay clearance of fetal lung fluid and increase the risk of transient tachypnoea of the newborn and other respiratory complications [3,6]. The neonatal outcome following a previous caesarean delivery is particularly important because women with a previous LSCS may undergo either repeat elective LSCS or a trial of labour resulting in VBAC. VBAC can avoid repeat abdominal surgery and may reduce maternal morbidity associated with multiple caesarean deliveries, but it requires appropriate patient selection and facilities for emergency intervention when necessary [7-9]. Studies comparing repeat elective caesarean delivery with VBAC have reported differences in NICU admission, respiratory morbidity, oxygen requirement and neonatal complications [3,10]. Previous studies have also reported that successful VBAC may be associated with lower neonatal intervention and NICU admission rates, whereas elective repeat caesarean delivery has been associated with increased respiratory morbidity [3,10]. However, neonatal outcomes can vary according to gestational age, indications for caesarean delivery, antenatal risk factors and the availability of neonatal care. The present study was undertaken to compare neonatal morbidity and mortality among neonates delivered by E-LSCS, R-LSCS and VBAC. The study specifically assessed Apgar scores, birth weight, NICU admission, respiratory morbidity, hypoglycaemia, sepsis, phototherapy requirement and duration of NICU stay. The study was undertaken because there is limited comparative information on neonatal outcomes following E-LSCS, repeat E-LSCS and VBAC in the local Indian setting. Generating such evidence may help clinicians in counselling women with previous caesarean delivery and in selecting an appropriate mode of delivery while considering neonatal safety [8-10].

Study design and setting A hospital-based observational clinical study was conducted at Al Ameen Women and Children Hospital attached to Al Ameen Medical College, Vijayapur. The study included neonates delivered between June 2013 and May 2015. During the study period, there were 500 deliveries, of which 90 neonates fulfilled the study criteria and were included in the analysis. Study population A total of 90 neonates were studied and divided equally into three groups: • Group I: Elective LSCS (E-LSCS), n=30 • Group II: Repeat elective LSCS (R-LSCS), n=30 • Group III: Vaginal birth after caesarean (VBAC), n=30. Inclusion Criteria Neonates born following elective LSCS, repeat elective LSCS or VBAC in singleton pregnancies with vertex presentation and gestational age of ≥37 weeks were included. Exclusion Criteria Neonates were excluded if they had: 1. Congenital anomalies 2. Malpresentation 3. Multifetal gestation 4. Maternal gestational diabetes, hypertension or other significant medical disorders 5. Gestational age <37 weeks Parameters assessed: The following neonatal parameters were recorded: 1. Apgar score at 1 and 5 minutes 2. Birth weight 3. Requirement for resuscitation and oxygen 4. NICU admission 5. Respiratory morbidity 6. Meconium-stained amniotic fluid/meconium aspiration syndrome 7. Hypoglycaemia 8. Physiological jaundice and requirement for phototherapy 9. Neonatal sepsis 10. Duration of NICU stay 11. Neonatal mortality, if any Respiratory morbidity included respiratory distress, transient tachypnoea of the newborn, respiratory distress syndrome, meconium aspiration syndrome and the requirement for bag-mask ventilation or intubation. Neurological morbidity and infectious complications were also recorded where present. Statistical analysis: Data were entered and analysed using Microsoft Excel and SPSS version 11.5. Continuous variables were expressed as mean ± standard deviation, while categorical variables were expressed as numbers and percentages. Categorical variables were compared using the chi-square test or Fisher exact test. One-way analysis of variance was used to compare continuous variables among the three groups. A p-value <0.05 was considered statistically significant.

A total of 90 neonates were included, with 30 neonates in each group. The study population represented 18% of the 500 deliveries during the study period. Indications for delivery The commonest indication for E-LSCS was cephalopelvic disproportion (16/30; 53.3%), followed by failure to progress (20%), maternal desire (13.3%) and post-dated pregnancy (10%). In the R-LSCS group, previous LSCS was the predominant indication (28/30; 93.3%). The distribution of indications differed significantly among the groups (p<0.001) as indicated in Table 1. Table 1: Indications distribution of patients studied Indications E-LSCS (n=30) R-LSCS (n=30) VBAC (n=30) Total (n=90) Nil 0(0%) 0(0%) 30(100%) 30(33.3%) Yes 30(100%) 30(100%) 0(0%) 60(66.7%) CPD 16(53.3%) 1(3.3%) 0(0%) 17(18.9%) Prev.LSCS 0(0%) 28(93.3%) 0(0%) 28(31.1%) FTP 6(20%) 0(0%) 0(0%) 6(6.7%) MD 4(13.3%) 0(0%) 0(0%) 4(4.4%) POST-DATED 3(10%) 0(0%) 0(0%) 3(3.3%) OBESE+CPD 1(3.3%) 0(0%) 0(0%) 1(1.1%) PD+FP 0(0%) 1(3.3%) 0(0%) 1(1.1%) P<0.001**, Significant, Fisher Exact test Gender distribution Of the 90 neonates, 48 (53.3%) were male and 42 (46.7%) were female. Male neonates constituted 60% of the E-LSCS group, 53.3% of the R-LSCS group and 46.7% of the VBAC group. The difference was not statistically significant (p=0.585). Table 2: Gender distribution of patients studied Gender E-LSCS R-LSCS VBAC Total Female 12(40%) 14(46.7%) 16(53.3%) 42(46.7%) Male 18(60%) 16(53.3%) 14(46.7%) 48(53.3%) Total 30(100%) 30(100%) 30(100%) 90(100%) P=0.585, Not significant, Chi-Square test Gestational age Most neonates were delivered between 37 and 40 weeks of gestation. This included 56.7% of neonates in the E-LSCS group, 73.3% in the R-LSCS group and 90% in the VBAC group. Neonates delivered at 41-42 weeks constituted 43.3%, 26.7% and 10% of the respective groups. The difference in gestational age distribution was statistically significant (p=0.014). Table 3: Gestational Age in week’s distribution of patients studied Gestational age E-LSCS R-LSCS VBAC Total 37-40 17(56.7%) 22(73.3%) 27(90%) 66(73.3%) 41-42 13(43.3%) 8(26.7%) 3(10%) 24(26.7%) Total 30(100%) 30(100%) 30(100%) 90(100%) P=0.014*, significant, Chi-Square test Apgar score At 1 minute, an Apgar score <7 was observed in 20% of neonates in the E-LSCS group, 16.7% in the R-LSCS group and 26.7% in the VBAC group. At 5 minutes, an Apgar score <7 was observed in 3.3%, 3.3% and 10% of neonates in the respective groups. These differences were not statistically significant. The mean Apgar scores at 1 minute were 6.56±0.89, 6.47±1.14 and 6.30±1.03 in the E-LSCS, R-LSCS and VBAC groups, respectively (p=0.873). At 5 minutes, the corresponding values were 8.43±0.63, 8.33±0.66 and 8.37±0.76 (p=0.737). Table 4a: Apgar score distribution of patients studied Apgar Score E-LSCS (n=30) R-LSCS (n=30) VBAC (n=30) Total (n=90) P value 1 min • <7 6(20%) 5(16.7%) 8(26.7%) 19(21.1%) 0.627 • >7 24(80%) 25(83.3%) 22(73.3%) 71(78.9%) 5 min • <7 1(3.3%) 1(3.3%) 3(10%) 5(5.5%) 0.429 • >7 29(96.7%) 29(96.7%) 27(90%) 85(94.5%) Table 4b: Apgar score distribution of patients studied Apgar Score E-LSCS (n=30) R-LSCS (n=30) VBAC (n=30) Total (n=90) P value 1 min 6.56±0.89 6.47±1.14 6.30±1.03 6.54±1.01 0.873 5 min 8.43±0.63 8.33±0.66 8.37±0.76 8.31±0.68 0.737 Birth weight Most neonates weighed between 2.5 and 3.5 kg. The proportion was 90% in the E-LSCS group, 86.7% in the R-LSCS group and 76.7% in the VBAC group. The proportion of neonates weighing <2.5 kg was 10%, 13.3% and 23.3%, respectively. The mean birth weights were 2.80±0.39 kg, 2.85±0.43 kg and 2.65±0.41 kg in the E-LSCS, R-LSCS and VBAC groups, respectively. The difference was not statistically significant (p=0.139). Table 5: Birth Weight (kg) distribution of patients studied Birth Weight (kg) E-LSCS R-LSCS VBAC Total <2.5 3(10%) 4(13.3%) 7(23.3%) 14(15.6%) 2.5-3.5 27(90%) 26(86.7%) 23(76.7%) 76(84.4%) >3.5 0(0%) 0(0%) 0(0%) 0(0%) Total 30(100%) 30(100%) 30(100%) 90(100%) Mean ± SD 2.80±0.39 2.85±0.43 2.65±0.41 2.77±0.42 P=0.139, Not significant, ANOVA test NICU admission NICU admission was required in 11 (36.6%) neonates in the E-LSCS group, 11 (36.6%) in the R-LSCS group and 9 (30%) in the VBAC group. Although NICU admission was numerically higher in both caesarean groups, the difference was not statistically significant (p=0.821). Table 6: NICU distribution of patients studied NICU E-LSCS R-LSCS VBAC Total No 19(63.33%) 19(63.33%) 21(70%) 59(65.55%) Yes 11(36.66%) 11(36.66%) 9(30%) 31(34.44%) Total 30(100%) 30(100%) 30(100%) 90(100%) P=0.821, significant Indications for NICU admission Cause E-LSCS (n=30) R-LSCS (n=30) VBAC (n=30) Total (n=90) Nil 19(63.33%) 19(63.33%) 21(66.7%) 59(65.5%) Yes 11(36.66%) 11(36.66%) 9(33.3%) 31(34.4%) • RD 8(26.6%) 6(20%) 1(3.33%) 17(18.9%) • BA 1(3.3%) 2(6.66%) 0(0%) 3(3.3%) • Birth injury+BA 0(0%) 0(0%) 1(3.3%) 1(1.1%) • LBW +Sepsis 0(0%) 0(0%) 1(3.3%) 1(1.1%) • LBW+Hypoglycemia 1(3.33%) 0(0%) 2(6.7%) 3(3.3%) • MAS 0(0%) 1(3.33%) 1(3.3%) 2(2.2%) • RD+LA 1(3.33%) 1(3.3%) 2(6.7%) 4(4.4%) • Sepsis 0(0%) 1(3.3%) 1(3.33%) 2(2.2%) Table 7: Indications for NICU admission Respiratory distress was the most frequent indication for NICU admission among neonates delivered by E-LSCS and R-LSCS. Respiratory distress occurred in 26.6% of the E-LSCS group and 20% of the R-LSCS group compared with 3.3% in the VBAC group. Other indications included birth asphyxia, hypoglycemia, meconium aspiration syndrome, sepsis, low birth weight and birth injury. The overall distribution of indications for NICU asmission was not statistically significant (p=1.000). Phototherapy Phototherapy was required in 46.7% of neonates in the E-LSCS group, 50% in the R-LSCS group and 43.3% in the VBAC group. The difference was not statistically significant (p=0.875). Table 8: PT distribution of patients studied PT E-LSCS R-LSCS VBAC Total No 16(53.3%) 15(50%) 17(56.7%) 48(53.3%) Yes 14(46.7%) 15(50%) 13(43.3%) 42(46.7%) Total 30(100%) 30(100%) 30(100%) 90(100%) P=0.875, Not significant, Chi-Square test Sepsis Sepsis was diagnosed in 7 (23.3%) neonates in the E-LSCS group, 8 (26.7%) in the R-LSCS group and 9 (30%) in the VBAC group. Although the highest proportion was observed in the VBAC group, the difference was not statistically significant (p=0.843). Table 9: Sepsis incidence of patients studied Sepsis E-LSCS R-LSCS VBAC Total No 23(76.7%) 22(73.3%) 21(70%) 66(73.3%) Yes 7(23.3%) 8(26.7%) 9(30%) 24(26.7%) Total 30(100%) 30(100%) 30(100%) 90(100%) P=0.843, Not significant, Chi-Square test. Duration of NICU stay Among neonates admitted to the NICU, 23.3% of the E-LSCS group, 20% of the R-LSCS group and 20% of the VBAC group stayed for less than 5 days. A stay of 5-10 days was observed in 10%, 10% and 6.7% of neonates, respectively. A stay of more than 10 days was observed in 3.3%, 6.6% and 3.3% of neonates, respectively. The difference was not statistically significant (p=0.986). No neonatal mortality was documented among the 90 neonates included in the present study. Table 10: NICU Stay of patients studied NICU Stay E-LSCS (n=30) R-LSCS (n=30) VBAC (n=30) Total (n=90) Nil 19(63.3%) 19(63.3%) 21(70%) 59(65.5%) Yes 11(36.6%) 11(36.6%) 9(30%) 31(34.4%) • <5 days 7(23.3%) 6(20%) 6(20%) 19(21.1%) • 5-10 days 3(10%) 3(10.0%) 2(6.7%) 8(8.8%) • >10 days 1(3.3%) 2(6.6%) 1(3.3%) 4(4.4%) P=0.986,Not significant, Chi-Square test

The present study compared neonatal outcomes following E-LSCS, R-LSCS and VBAC in 90 term neonates. The increasing use of caesarean delivery has raised concerns regarding neonatal respiratory morbidity and NICU utilisation, particularly when caesarean delivery is performed without labor [3,4]. The present findings showed that NICU admission was more frequent among neonates delivered by E-LSCS and R-LSCS than among those delivered by VBAC, although the difference was not statistically significant. This observation is consistent with previous reports showing increased NICU admission and neonatal respiratory morbidity following elective repeat caesarean delivery compared with successful VBAC [3,10]. In the present study, respiratory distress was the most common indication for NICU admission among neonates in the E-LSCS and R-LSCS groups. This finding is biologically plausible because labour contributes to fetal lung-fluid clearance, while neonates delivered by caesarean section without labour may have delayed clearance of pulmonary fluid [6]. Kamath et al. reported higher respiratory morbidity following elective caesarean delivery, particularly transient tachypnoea of the newborn, and observed that respiratory morbidity decreased with increasing gestational age [3]. Eriksen and Buttino also reported an association between mode of delivery and neonatal respiratory morbidity at term [4]. The mean Apgar score at 5 minutes was slightly lower in the VBAC group than in the E-LSCS and R-LSCS groups, although the difference was not statistically significant. An Apgar score <7 at 5 minutes was observed in 10% of VBAC neonates compared with 3.3% in each caesarean group. Similar observations have been reported in studies evaluating neonatal outcomes following previous caesarean delivery, although differences in Apgar scores between VBAC and repeat caesarean delivery are not consistently statistically significant [8,9]. Proper antenatal assessment and continuous intrapartum monitoring remain important during a trial of labour because unsuccessful labour or fetal compromise can affect neonatal outcome [7,9]. Birth weight did not differ significantly among the three groups. The mean birth weight was highest in the R-LSCS group and lowest in the VBAC group. The proportion of neonates weighing less than 2.5 kg was also numerically higher in the VBAC group. However, because the overall difference was not significant, mode of delivery alone cannot be considered responsible for the observed variation in birth weight. Previous studies comparing neonatal outcomes after VBAC and repeat caesarean delivery have similarly reported no consistent significant difference in neonatal birth weight [8,9]. Sepsis was observed in 23.3% of neonates following E-LSCS, 26.7% following R-LSCS and 30% following VBAC. Although the proportion was highest in the VBAC group, the difference was not statistically significant. The requirement for phototherapy was also comparable between the groups. These findings indicate that not all neonatal morbidities were associated with the mode of delivery. Other maternal, intrapartum and neonatal factors may contribute to sepsis and jaundice. The findings of the present study are also comparable with observations reported by Goel et al., who concluded that trial of labour after a previous caesarean delivery could reduce unnecessary repeat caesarean deliveries when women are appropriately selected and managed in adequately equipped hospitals [8]. Similarly, studies evaluating VBAC have highlighted the importance of appropriate selection, antenatal counselling and the availability of facilities for emergency caesarean delivery [7,9]. The present study therefore supports the view that VBAC can be considered in appropriately selected women rather than routinely performing repeat caesarean delivery after a previous LSCS. The present study has some limitations. It was conducted at a single centre and included a relatively small sample of 90 neonates. The study was observational and therefore cannot establish a causal relationship between mode of delivery and neonatal morbidity. In addition, the groups may have differed in gestational age and indications for delivery. Nevertheless, the study provides useful comparative information on neonatal outcomes among E-LSCS, R-LSCS and VBAC in an Indian hospital setting.

The present study demonstrates that neonatal outcomes following E-LSCS, R-LSCS and VBAC were broadly comparable for several parameters. NICU admission was numerically higher following E-LSCS and R-LSCS than VBAC, although the difference was not statistically significant. Respiratory distress was the major indication for NICU admission among neonates delivered by E-LSCS and R-LSCS. Apgar scores, birth weight, phototherapy requirement, sepsis and duration of NICU stay did not show statistically significant differences among the three groups. No neonatal mortality was recorded in the study. These findings suggest that VBAC may be a reasonable option for appropriately selected women with a previous caesarean delivery when adequate antenatal counselling, intrapartum monitoring and emergency obstetric and neonatal care facilities are available.

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