Neonatal outcomes between trial of labor and cesarean delivery for extreme preterm infants

Objective: To compare adverse neonatal outcomes between trial of vaginal delivery and upfront cesarean delivery for singleton infants born at 24 to 28 weeks of gestation. Methods: This is a retrospective cohort study that was conducted at a university-affiliated tertiary medical center between 2011 and 2022, involving singleton pregnancies delivered between 240/7 and 276/7 weeks of gestation. Participants were divided into two groups based on their intended mode of delivery: a trial of labor (TOL) group and an upfront cesarean delivery (CD) group. The primary outcome was defined as neonatal death. The secondary outcome was defined as any of the following: intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, neonatal sepsis, periventricular leukomalacia, disseminated intravascular coagulation, umbilical cord arterial PH <7.1, or use of postpartum mechanical ventilation. Analyses were performed using an intention-to-treat approach. Results: Overall, 199 patients were enrolled, with 64 in the TOL group and 135 in the upfront CD group. Neonatal deaths occurred in 48 cases (24.2%) across the entire cohort, with no significant difference between the TOL (18.8%) and upfront CD (26.7%) groups (P = 0.223). Rates of other composite adverse outcome were comparable between the groups (26.6% vs. 31.9%, P = 0.448), respectively. A sub-analysis comparing patients with pre-existing contraindications for vaginal delivery, without maternal or fetal indications for delivery, to those in the TOL group who experienced spontaneous onset of labor showed no differences in primary or secondary outcomes between the groups. Conclusion: We found no difference in adverse neonatal outcomes between TOL and upfront CD for singletons born at 24-28 weeks gestation.