Trial of Labor and Neonatal Outcomes in Extreme prematurity <28 Weeks' Gestation 

Trial of Labor and Neonatal Outcomes in Extreme prematurity <28 Weeks' Gestation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Trial of Labor and Neonatal Outcomes in Extreme prematurity <28 Weeks' Gestation Itamar Gilboa, Daniel Gabbai, Yariv Yogev, Anat Lavie, Emmanuel Attali, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4885592/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND The optimal mode of delivery for extremely preterm infants remains a subject of debate, particularly concerning the potential benefits of planned cesarean delivery. OBJECTIVE This study aimed to compare adverse neonatal outcomes between planned cesarean delivery and a trial of labor for singleton infants born before 28 weeks of gestation. STUDY DESIGN We conducted a retrospective cohort study of all singleton pregnancies delivered between 24 0/7 and 27 6/7 weeks of gestation at a single university-affiliated tertiary medical center. Patients were categorized into two groups: patients who opted a trial of vaginal delivery (TOL group) and those who had planned cesarean delivery (CD group). The primary outcome included neonatal death before discharge and severe neurological injury. Postnatal outcomes were recorded during hospitalization before discharge, and data were analyzed using an intention-to-treat analysis. Additional sub-analyses included women with spontaneous onset of labor without maternal or neonatal delivery indications and those within the gestational age range of 25 0/7 to 27 6/7 weeks. RESULTS A total of 199 patients were eligible for inclusion: 64 opted a trial of vaginal delivery (TOL group), while 135 underwent planned cesarean delivery (CD group). Within the TOL group, there was a higher incidence of delivery at 24 0/7 - 24 6/7 weeks of gestation. Five women (7.8%) in the TOL group underwent intrapartum urgent CD. No disparities in the rates of primary or overall composite outcomes were observed between the TOL and CD groups (26.6% vs. 31.9%, p = 0.448 and 85.9% vs. 90.4%, p = 0.352, respectively). Adjusted multivariate analysis did not find significance between a trial of labor or planned cesarean delivery. CONCLUSIONS In extreme preterm births between 24–28 weeks of gestation no difference was found for the risk for adverse neonatal outcomes between those who had a trial of labor and those who underwent planned cesarean delivery. cesarean delivery mode of delivery neonatal morbidity neonatal mortality preterm delivery extreme preterm birth Figures Figure 1 INTRODUCTION Preterm birth (PTB) is the leading cause of neonatal morbidity and mortality ( 1 , 2 ), which are inversely related to gestational age at delivery ( 3 ). In extreme PTB, commonly defined as birth < 28 weeks of gestation ( 4 ), neonatal mortality can reach up to 50% with similar rates of morbidity among survivors ( 5 – 7 ). Therefore, efforts are invested in both preventing extreme prematurity and optimizing medical care in those cases. While some interventions, such as the administration of antenatal corticosteroids and magnesium sulphate, have been shown to be beneficial in decreasing neonatal complications ( 8 – 10 ), the optimal mode of delivery (MOD) in cases of PTB < 28 weeks of gestation remains controversial. Some studies suggest that in extreme prematurity, cesarean delivery (CD) is associated with reduced rates of neonatal mortality ( 11 , 12 ) and improved long-term survival ( 13 , 14 ) in comparison to vaginal delivery. Other studies, however, reported no significant neonatal differences related to MOD of extreme prematurity ( 15 – 21 ), while some reported an increased risk of neonatal morbidity with CD ( 22 – 24 ). Nevertheless, most prior studies compared cases of CD with cases of successful vaginal delivery without taking into consideration a trial of labor (TOL). However, in cases of TOL, birth can be either vaginal or rather an emergent CD, which is usually performed in suboptimal conditions and can adversely affect perinatal outcome, and might underestimate the potential benefits of primary CD in those cases ( 18 , 25 ). Other limitations of prior studies include a relatively small sample size ( 16 ), heterogeneity among groups with gestational age ranging up to 34 weeks ( 11 , 17 ), and failure to adjust for potential confounding factors such as the indication or etiology of PTB ( 11 , 18 , 25 ). Hence, our aim was to assess the optimal MOD for cases of extreme PTB occurring before 28 weeks of gestation, using an intention-to-treat approach. This was achieved by comparing outcomes between a TOL and planned CD without attempting labor. METHODS Study Population A retrospective cohort study of all patients who gave birth between 24 0/7 – 27 6/7 weeks of gestation in a single university-affiliated tertiary medical center (2011–2022). It was approved by the institutional review board (0284-08-TLV) which waived informed consent due to its retrospective design and anonymized data. Exclusion criteria included multiple gestations,and non-viable fetuses,. In our institute, at extreme prematurity patients are consulted regarding mode of delivery (MOD) and the choice of CD is given even in the lack of contraindication for trial of labor. The decision regarding MOD is then determined based on standard obstetrical indications, patients' preferences, and physicians' preferences. We included all qualifying pregnancies delivered during the study period. Data source Maternal and neonatal data were obtained from the computerized medical records. We retrieved maternal and pregnancy data, including: maternal age, body mass index (BMI), parity, surgical history, gestational age (GA) at delivery, mode of conception, onset of labor, indication for CD, antepartum corticosteroids administration (considered only if patients received full course), administration of Magnesium sulphate (Mg) for neuroprotection, and pregnancy complications. The following data were collected from the neonatal records: Apgar score at 1 and 5 min, arterial blood PH, birthweight and neonatal complications: necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), mechanical ventilation, bronchopulmonary dysplasia (BPD), periventricular leukomalacia (PVL), and newborn death before discharge. Postnatal outcomes were recorded during hospitalization before discharge. Chorioamnionitis was defined based on clinical suspicion by obstetricians at the time of delivery. The diagnosis typically involved the presence of maternal fever of 38°C accompanied one of the following: fetal tachycardia (above 160 beats per minute), maternal leukocytosis > 15,000 in the absence of corticosteriods, purulent fluid from the external os, and uterine sensitivity. In some cases, chorioamnionitis was confirmed post-delivery through positive cultures from the placenta ( 26 , 27 ). Pathologic blood flow was defined as absent or reversed end-diastolic flow in the umbilical artery or absent or reversed "A-wave" in the ductus venosus. Exposure The exposure of interest was trial of labor. Neonatal outcomes were compared between those with vertex presentation who opted for vaginal delivery ( TOL group) regardless of the eventual mode of delivery (vaginal/cesarean delivery) and those who opted for planned CD ( CD group ). Patients with a-priori indication for CD (e.g. non-vertex presentation, placenta previa) were included in the CD group. Patients who opted a TOL and had eventually maternal or fetal indications for urgent CD during labor, were included in the TOL group, in an intention-to-treat approach. Outcomes The primary outcome was a composite adverse neonatal outcome, defined as one or more of the following: ( 1 ) neonatal death prior to discharge; ( 2 ) severe neurological injury, defined as grade 3 or 4 intraventricular hemorrhage ( 28 ). Overall composite outcome included any of the abovementioned or any of the following: (NEC) stage 2 or 3 (29), bronchopulmonary dysplasia (BPD) (30), periventricular leukomalacia (PVL), neonatal sepsis, disseminated intravascular coagulation (DIC), arterial blood PH < 7.1, or mechanical ventilation. Statistical Analysis The categorical variables were presented as frequency and percentage. Normality of the continuous variables was tested using the Kolmogorov–Smirnov test and given as means ± standard deviation if normally distributed or median and interquartile range if normality could not be assumed. Comparisons between the groups were performed with the Student t-test for normally distributed continuous variables and with the Mann-Whitney rank sum test for non-normally distributed continuous variables. The Chi-square and Fisher’s exact tests were used for comparing categorical variables. A multivariable logistic regression model, controlling for variables found to be statistically different between groups with p < 0.1 in the univariate analysis, in addition to variables that were chosen a priori such as gestational age at birth, newborn birthweight, antepartum steroids, magnesium, and newborn sex, was used to identify variables independently associated with the study outcomes. Groups were analyzed according to intention to treat. Two distinct sub-analyses were conducted. The first focused on women experiencing spontaneous labor onset without maternal or neonatal delivery indications. The second analyzed women within the gestational age range of 25 0/7 to 27 6/7 weeks, considering the elevated mortality risk in newborns born before 25 weeks of gestation. All statistical analyses were performed using SPSS software (SPSS version 29, IBM, Chicago). RESULTS Among 131,019 women delivering between 24 0/7 -27 6/7 weeks of gestation during the study period, 199 met the study criteria (Figure 1). The Trial of Labor (TOL) group comprised of 64 women (32.2%), among whom 5 (7.8%) eventually underwent urgent cesarean delivery (CD), with 4 (6.3%) due to non-reassuring fetal heart monitoring (NRFHM) and 1 (1.6%) due to placental abruption. The planned CD group comprised 135 women (67.8%), of whom 73 women (54.1%) had a contraindication for TOL. This included 67 cases (49.6%) with a fetus in a non-vertex presentation and 6 cases (4.4%) with placenta previa. Maternal and obstetrical characteristics are delineated in Table 1. Within the TOL group, there were higher rates of delivery occurring between 24 0/7 -24 6/7 weeks of gestation and spontaneous onset of labor. Conversely, the planned CD group had higher rates of preeclampsia (PE)/Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) syndrome, as well as non-reassuring fetal heart monitoring (NRFHM) (Table 1). Table 1. Baseline characteristics of the TOL and planned CD Groups. TOL group (n=64) Planned CD group (n=135) p-value Maternal age, mean (SD) 32.8 (6.4) 33.5 (6.2) 0.485 Gestational age, median (IQR) 26.0 (24.5-27.0) 25.6 (24.5-26.4) 0.593 Gestational age 24 0/7 -24 6/7 , n (%) 16 (25.0%) 17 (12.6%) 0.028 Gestational age 25 0/7 -25 6/7 , n (%) 11 (17.2%) 38 (28.1%) 0.094 Gestational age 26 0/7 -26 6/7 , n (%) 19 (29.7%) 35 (25.9%) 0.577 Gestational age 27 0/7 -27 6/7 , n (%) 18 (28.1%) 46 (34.1%) 0.401 Pre-gestational BMI, median (IQR) 21.8 (20.5-25.4) 23.0 (19.7-23.9) 0.887 IVF, n (%) 12 (18.8%) 33 (24.4%) 0.370 Nulliparity, n (%) 38 (59.4%) 64 (47.4%) 0.115 Previous CD, n (%) 6 (9.4%) 21 (15.6%) 0.234 Antepartum steroids, n (%) 43 (67.2%) 91 (67.9%) 0.919 Mg, n (%) 47 (73.4%) 83 (61.9%) 0.111 Spontaneous onset of labor, n (%) 64 (100%) 59 (43.7%) <0.001 PPROM, n (%) 22 (37.3%) 27 (27.0%) 0.175 Uterine rupture, n (%) 0 6 (4.5%) 0.084 PE/HELLP, n (%) 0 20 (14.8%) 0.001 Placental abruption, n (%) 12 (18.8%) 28 (20.7%) 0.743 Chorioamnionitis, n (%) 7 (10.9%) 20 (14.8%) 0.456 Pathological blood flow, n (%) 0 7 (5.2%) 0.064 NRFHM, n (%) 4 (6.3%) 29 (21.5%) 0.007 Meconium, n (%) 10 (15.6%) 18 (13.4%) 0.679 Newborn weight, grams (mean ,SD) 857 (189) 818 (185) 0.823 Female sex, n (%) 25 (39.1%) 72 (53.3%) 0.060 Abbreviations: IVF, in-vitro-fertilization; CD, cesarean delivery; BMI, body-mass-index (kg/m 2 ); Mg, magnesium for neuroprotection; PPROM, preterm premature rupture of membranes; PE, preeclampsia; HELLP, hemolysis elevated liver enzymes, low platelets; NRFHM , non-reassuring fetal heart monitor; SD, standard deviation; IQR, interquartile range Table 2 presents neonatal outcomes. Among the entire cohort, neonatal death occurred in 48 cases (24.2%), with no significant differences observed between the TOL and planned CD groups (19.0% vs. 26.7%, p=0.244). Similarly, there were no significant differences between the TOL and CD groups concerning the rates of primary (26.6% vs. 31.9%, p=0.448) and overall composite outcomes (85.9% vs. 90.4%, p=0.352). Furthermore, the rates of individual components of secondary outcomes and overall composite outcomes did not vary between the groups (Table 2). Table 2. Comparison of neonatal outcomes in patients with a TOL and planned CD TOL group (n=64) Planned CD group (n=135) p-value Primary composite outcome, n (%) a 17 (26.6%) 43 (31.9%) 0.448 Overall composite outcome, n (%) b 55 (85.9%) 122 (90.4%) 0.352 Death, n (%) 12 (19.0%) 36 (26.7%) 0.244 5-min Apgar < 7, n (%) 21 (32.8%) 52 (38.5%) 0.435 Umbilical arterial PH<7.1, n (%) 6 (9.4%) 6 (4.4%) 0.172 Mechanical ventilation, n (%) 45 (70.3%) 99 (73.3%) 0.656 BPD, n (%) 32 (50.0%) 68 (50.4%) 0.961 IVH, n (%) 9 (14.1%) 15 (11.1%) 0.550 NEC, n (%) 8 (12.5%) 15 (11.1%) 0.775 PVL, n (%) 5 (7.8%) 9 (6.7%) 0.768 Sepsis, n (%) 7 (10.9%) 15 (11.1%) 0.971 DIC, n (%) 1 (1.6%) 5 (3.7%) 0.409 Abbreviations:; BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage (grade 3/4); NEC, necrotizing enterocolitis (stage 2/3); PVL, periventricular leukomalacia; DIC, disseminated intravascular coagulation; SD, standard deviation; IQR, interquartile range a Defined as one or more of the following: newborn death prior to discharge, severe neurological injury. b Defined as one or more of the following: newborn death prior to discharge, severe neurological injury, NEC (stage 2/3), BPD, PVL, mechanical ventilation, neonatal sepsis, arterial ph< 7.1, and DIC Multivariate analysis, adjusted for gestational age, newborn birthweight, gender, magnesium for neuroprotection, antepartum steroids, spontaneous onset of labor, uterine rupture, non-reassuring fetal heart rate, HELLP syndrome, and pathological blood flow, did not find significant differences between a TOL and CD. In order to determine the potential impact of TOL on neonatal outcomes, we conducted a sub-analysis, limited to pregnancies with spontaneous onset of labor. The TOL group consisted of 44 deliveries, while the CD group comprised 39 deliveries. Within the TOL group, one delivery (2.3%) required conversion to urgent CD. Notably, among the CD group, 92.3% had a predetermined indication for CD (non-cephalic presentation), while the remaining opted for CD without TOL. Maternal and obstetrical characteristics were comparable between the groups (Table 3). Table 3. Subgroup analysis - baseline characteristics of the TOL and planned CD groups with spontaneous onset of labor. TOL (n=44) Planned CD group (n=39) p-value Maternal age, (mean ,SD) 33.0 (6.4) 34.5 (6.4) 0.801 Pre- gestational BMI, median (IQR) 21.8 (20.5-25.4) 23.0 (19.7-23.9) 0.593 Gestational age, median (IQR) 26.0 (24.5-27.0) 25.6 (24.5-26.4) 0.887 Gestational age 24 0/7 -24 6/7 , n (%) 14 (31.8%) 9 (23.1%) 0.375 Gestational age 25 0/7 -25 6/7 , n (%) 9 (20.5%) 10 (25.6%) 0.575 Gestational age 26 0/7 -26 6/7 , n (%) 11 (25.0%) 10 (25.6%) 0.947 Gestational age 27 0/7 -27 6/7 , n (%) 10 (22.7%) 10 (25.6%) 0.757 Conception (IVF), n (%) 7 (15.9%) 6 (15.4%) 0.948 Nulliparity, n (%) 29 (65.9%) 18 (46.2%) 0.070 Previous CD, n (%) 5 (11.4%) 5 (12.8%) 0.839 Antepartum steroids, n (%) 30 (68.2%) 26 (68.4%) 0.981 Mg, n (%) 32 (72.7%) 22 (57.9%) 0.158 PPROM, n (%) 15 (37.5%) 11 (44.0%) 0.603 Non-vertex presentation, n (%) 0 36 (92.3%) <0.001 Placenta previa, n (%) 0 0 NA Meconium, n (%) 7 (15.9%) 3 (7.7%) 0.251 Newborn weight, grams (mean ,SD) 835 (202) 847 (165) 0.326 Female sex, n (%) 16 (36.4%) 20 (51.3%) 0.171 Abbreviations: IVF, in-vitro-fertilization; CD, cesarean delivery; BMI, body-mass-index (kg/m 2 ); Mg, magnesium for neuroprotection; PPROM, preterm premature rupture of membranes; SD, standard deviation; IQR, interquartile range Similarly, rates of primary and overall composite outcomes were similar between the groups (Table 4). Table 4. Subgroup analysis - neonatal outcomes of TOL and planned CD groups comparing only cases with spontaneous onset of labor. TOL group (n=44) Planned CD group (n=39) p-value Primary composite outcome, n (%) a 11 (25.0%) 9 (23.1%) 0.838 Overall composite outcome, n (%) b 39 (88.6%) 35 (89.7%) 0.871 Death, n (%) 10 (23.3%) 7 (17.9%) 0.554 Apgar < 7 (5 min), n (%) 17 (38.6%) 12 (37.5%) 0.920 Umbilical arterial PH <7.1, n (%) 5 (11.4%) 1 (2.6%) 0.122 Mechanical ventilation, n (%) 31 (70.5%) 31 (79.5%) 0.345 BPD, n (%) 24 (54.5%) 25 (64.1%) 0.377 IVH, n (%) 6 (13.6%) 4 (10.3%) 0.637 NEC, n (%) 5 (11.4%) 6 (15.4%) 0.590 PVL, n (%) 4 (9.1%) 3 (7.7%) 0.819 Sepsis, n (%) 3 (6.8%) 5 (12.8%) 0.355 DIC, n (%) 0 0 NA Abbreviations BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage (grade 3/4); NEC, necrotizing enterocolitis (stage 2/3); PVL, periventricular leukomalacia; DIC, disseminated intravascular coagulation; SD, standard deviation; IQR, interquartile range a Defined as one or more of the following: newborn death prior to discharge, severe neurological injury. b Defined as one or more of the following: newborn death prior to discharge, severe neurological injury, NEC (stage 2/3), BPD, PVL, mechanical ventilation, neonatal sepsis, arterial ph< 7.1, and DIC Given the significant disparities in preterm birth rates within the gestational age range of 24 0/7 -24 6/7 weeks, we conducted a supplementary sub-analysis excluding this period and focusing on pregnancies within the range of 25 0/7 -27 6/7 weeks. Within this gestational age range, the TOL group experienced higher rates of magnesium treatment for neuroprotection and spontaneous onset of labor. Conversely, the CD group exhibited increased prevalance of NRFHM and PE/HELLP syndrome (Table 5). Table 5. Subgroup analysis - baseline characteristics of the TOL and planned CD groups between 25 0/7 -27 6/7 weeks of gestation. TOL group (n=48) Planned CD group (n=118) p-value Maternal age, mean (SD) 32.6 (6.9) 33.2 (6.0) 0.097 Gestational age, median (IQR) 26.5 (26.0-27.2) 26.4 (25.6-27.2) 0.597 Gestational age 25 0/7 -25 6/7 , n (%) 11 (22.9%) 37 (31.4%) 0.277 Gestational age 26 0/7 -26 6/7 , n (%) 19 (39.6%) 35 (29.7%) 0.216 Gestational age 27 0/7 -27 6/7 , n (%) 18 (37.5%) 46 (39.0%) 0.859 Pre-gestational BMI, median (IQR) 21.7 (20.7-23.8) 22.5 (20.3-25.0) 0.531 IVF, n (%) 9 (18.8%) 29 (24.6%) 0.418 Nulliparity, n (%) 28 (58.3%) 56 (47.5%) 0.204 Previous CD, n (%) 4 (8.3%) 19 (16.1%) 0.189 Antepartum steroids, n (%) 35 (72.9%) 78 (66.7%) 0.433 Mg, n (%) 37 (77.1%) 70 (59.8%) 0.035 Spontaneous onset of labor, n (%) 48 (100%) 45 (38.1%) <0.001 PPROM, n (%) 14 (31.1%) 25 (27.8%) 0.687 Uterine rupture, n (%) 0 4 (3.4%) 0.193 PE/HELLP, n (%) 0 20 (16.9%) 0.002 Placental abruption, n (%) 11 (22.9%) 24 (20.3%) 0.712 Chorioamnionitis, n (%) 6 (12.5%) 19 (16.1%) 0.556 Pathological blood flow, n (%) 0 7 (5.9%) 0.085 NRFHM, n (%) 4 (8.3%) 28 (23.7%) 0.023 Meconium, n (%) 7 (14.6%) 17 (14.5%) 0.993 Newborn weight, grams (mean ,SD) 922 (164) 834 (190) 0.098 Female sex, n (%) 21 (43.8%) 63 (53.4%) 0.260 Abbreviations: IVF, in-vitro-fertilization; CD, cesarean delivery; BMI, body-mass-index (kg/m 2 ); Mg, magnesium for neuroprotection; PPROM, preterm premature rupture of membranes; PE, preeclampsia; HELLP, hemolysis elevated liver enzymes, low platelets; NRFHM , non-reassuring fetal heart monitor; SD, standard deviation; IQR, interquartile range Table 6 delineates neonatal outcomes in patients with a TOL and planned CD between 25 0/7 -27 6/7 weeks of gestation. Notably, no significant difference were found between the groups regarding primary and overall composite outcomes. However, the TOL group displayed a trend towards lower rates of neonatal mortality compared to the CD group, although statistical significance was not achieved (10.4% vs. 22.9%, p=0.065). Table 6. Subgroup analysis - comparison of neonatal outcomes in patients with a TOL and planned CD between 25 0/7 -27 6/7 weeks of gestation . TOL group (n=48) Planned CD group (n=118) p-value Primary composite outcome, n (%) a 9 (18.8%) 33 (28.0%) 0.216 Overall composite outcome, n (%) b 40 (83.3%) 105 (89.0%) 0.321 Death, n (%) 5 (10.4%) 27 (22.9%) 0.065 5-min Apgar < 7, n (%) 16 (33.3%) 41 (34.7%) 0.862 Umbilical arterial PH <7.1, n (%) 3 6.3%) 5 (4.2%) 0.583 Mechanical ventilation, n (%) 33 (68.8%) 86 (72.9%) 0.592 BPD, n (%) 27 (56.3%) 61 (51.7%) 0.594 IVH, n (%) 6 (12.5%) 11 (9.3%) 0.540 NEC, n (%) 7 (14.6%) 12 (10.2%) 0.418 PVL, n (%) 4 (8.3%) 8 (6.3%) 0.726 Sepsis, n (%) 5 (10.4%) 12 (10.2%) 0.962 DIC, n (%) 1 (2.1%) 5 (4.2%) 0.500 Abbreviations:; BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage (grade 3/4); NEC, necrotizing enterocolitis (stage 2/3); PVL, periventricular leukomalacia; DIC, disseminated intravascular coagulation; SD, standard deviation; IQR, interquartile range a Defined as one or more of the following: newborn death prior to discharge, severe neurological injury. b Defined as one or more of the following: newborn death prior to discharge, severe neurological injury, NEC (stage 2/3), BPD, PVL, mechanical ventilation, neonatal sepsis, arterial ph< 7.1, and DIC DISCUSSION Principal Findings In the current study we aimed to determine the effect of MOD on neonatal outcome in cases of singleton pregnancies delivered at <28 weeks of gestation. Our main findings were: While the rates of neonatal death did not reach statistical significance, it is possible that this outcome reflects the tendency for patients with urgent maternal or neonatal indications to undergo cesarean delivery. This could potentially account for the observed higher mortality rates in the CD group; 2) The rate of short term neonatal morbidity was not significantly different between TOL and CD groups; 3) In deliveries where a TOL was pursued, the majority of women attained vaginal delivery with relatively few cases needed an urgent CD. In addition, in those with spontaneous onset of labor, TOL was not associated with increased risk of neonatal morbidity compared to planned CD. Results in the Context of What is Known Mode of delivery for early preterm neonates has been a source of significant debate, a controversy that is mirrored in our study outcomes. Our study did not find significant differences in neonatal mortality and morbidity when comparing mode of delivery (MOD) within the gestational age range of 240/7-276/7 weeks. The question regarding optimal mode of delivery in early preterm neonates was recently addressed by two separate studies (18,25). In one study, the authors did not find increased neonatal morbidity or mortality in vaginal delivery compared to CD (18), while in the other study, the authors found that vaginal delivery was associated with increased risk for neonatal morbidity and mortality in cephalic fetuses, with the opposite results for non-cephalic fetuses (25). However, these studies were mainly limited by failure to adjust for potential confounding factors such as the indication of an early delivery. In addition, in both studies there is a lack of data concerning patients who had initially a trial of vaginal delivery and were taken for CD due to fetal or maternal indications, which in turn could have biased the results Previous studies showed potential link between cesarean deliveries (CD) and an increased risk for adverse neonatal outcomes. Malloy et al., noted a decreased risk of neonatal death among infants born through CD at 22-25 weeks of gestation (11). Similarly, Jarde et al. performed a meta-analysis encompassing singleton pregnancies below 28 weeks and found that cesarean deliveries were significantly correlated with reduced adjusted odds of death in those infants with vertex presentation (12). Conversely, other investigations have indicated that the mode of delivery might not have a substantial impact on neonatal outcomes (15–21). Zahedi-Spung et al. recently conducted a retrospective study involving singleton pregnancies delivered between 22 to 29 weeks’ gestation (18). Although cesarean delivery was linked with decreased risk for death in the delivery room or within 24 hours after birth, it did not lead to an overall improvement in morbidity or mortality. This also aligns with the findings of a large retrospective study by Hiersch et al. who explored the association of MOD and neonatal outcomes in twin pregnancies between 240/7-276/7 weeks of gestation and did not observed and significant differences between those who had a TOL and those who underwent cesarean delivery (19). In contrast, Bauer et al. reported an elevated risk of neonatal morbidity associated with CD compared to vaginal delivery in preterm births < 26 weeks of gestation (23). They also observed higher survival rates among newborns delivered vaginally. Additionally, Werner et al. suggested that neonatal mortality rates were comparable among newborns born between 24 and 34 weeks of gestation, while noting elevated rates of neonatal morbidity in the cesarean delivery group (22,24). More recently, Bitas et al. conducted an extensive study assessing mode of delivery and neonatal outcomes among 22-28 weeks of gestation (25). Their findings indicated that CD posed an increased risk for neonatal death in cephalic presentations compared to vaginal delivery (VD), while non-cephalic presentations showed higher risks for neonatal mortality and morbidity. In a recent meta-analysis led by Demertzidou et al., 27 retrospective studies on singleton pregnancies were examined to assess how the mode of delivery influences the perinatal outcomes of fetuses born before 32 weeks' gestation. The findings revealed that in infants delivered before 28 weeks, vaginal delivery notably heightened the risk of neonatal death within 28 days post-birth, regardless of presentation, particularly with breech presentation. However, when assessing survival before discharge, there was no discernible difference between the delivery groups (31). Clinical and research implications Overall, there is a lack of clear evidence regarding the optimal MOD for extremely preterm births. It appears that, ultimately, mortality and morbidity in this vulnerable group born before 28 weeks’ gestation are predominantly determined by their extreme prematurity. This may overshadow any minor variations linked to the mode of delivery, with no definitive neonatal benefit identified when contemplating MOD in extremely premature infants. While the lack of differences between groups could potentially be attributed to insufficient power, we believe this is less likely given that the point estimates were similar overall between the study and control groups. We hope that the findings of this study can assist caregivers when discussing the mode of delivery in cases of extreme preterm deliveries. Furthermore, they underscore the impact of extreme prematurity, highlighting the need for continued research to better understand the complex factors influencing neonatal outcomes in this population. It is noteworthy that although this study did not assess maternal outcomes or long-term infant and child outcomes, it revealed no significant neonatal benefit associated with cesarean delivery at this gestational age. However, it emphasizes the pivotal role of individualized decision-making in clinical practice. Patient preferences and future pregnancy plans are paramount considerations in guiding clinical decisions. This recommendation recognizes the multifaceted nature of clinical scenarios and highlights the importance of patient-centered care, which encompasses thoughtful consideration of maternal outcomes and further future evaluation. Strengths and limitations Our study boasts several noteworthy strengths. First, it had a specific focus on a highly distinct cohort of early preterm infants born between 240/7-276/7 weeks of gestation, which sets it apart from the majority of prior studies that primarily concentrated on infants with gestational ages below 34 weeks. Furthermore, while most prior studies concluded their results based on the actual mode of delivery, our study proposed a different perspective in which we included patients who had a vaginal trial of labor, whether they delivered eventually vaginally or were taken to cesarean delivery, to those who did not have a vaginal trial of labor, in an intention to treat approach, which assist to refine results and to negate possible confounders.. In addition, another significant advantage of our study lies in the detailed comparison we conducted between spontaneous VD and primary indication for CD. This sub-analysis allowed us to mitigate the influence of other variables that could potentially affect neonatal outcomes, particularly scenarios where deliveries commenced as vaginal but then required an immediate transition to cesarean delivery, due to medical indications. However, our study has several limitations. First, its retrospective design poses inherent constraints in terms of data collection and potential biases, in which we tried to overcome, and it should be taken into account when interpreting the results of our study. Furthermore, it should be noted that to be adequately powered (80%) to compare the study group with the control group, we will require approximately 720 patients in each group. Additionally, there was significant variation in presentation among our groups. The majority of newborns delivered via cesarean delivery, were not in cephalic presentation, whereas fetuses in the TOL were in cephalic presentation, contributing to heterogeneity. Moreover, in most cases, women with indications for early delivery within this gestational age range due to conditions such as PE/HELLP syndrome, or NRFHM, undergo CD without attempting a TOL. Although several indications for immediate delivery were included in our analysis, since it was not powered, they may have additional impact in which we could not demonstrate in our results. Consequently, our findings warrant caution due to this diversity within our study groups. It is worth noting that the cohort spans from 2011 to 2023, and neonatal mortality rates may have varied over this period. However, despite potential fluctuations, neonatal mortality rates remained consistent, estimated at around 24% for the gestational age range studied annually. CONCLUSION This study observed no disparity in the risk of adverse neonatal outcomes between individuals who pursued a trial of labor and those who underwent planned cesarean delivery among singleton early preterm births between 24 and 28 weeks of gestation. It is conceivable that extreme prematurity plays a pivotal role in determining neonatal outcomes within these cohorts. Moreover, our study implies that women who opt for a trial of labor have favorable prospects of achieving vaginal delivery, particularly given the relatively low rates of urgent cesarean deliveries. Nevertheless, it is imperative to interpret these findings judiciously due to the aforementioned limitations. Future prospective studies should validate these results and gather information on the reasons behind selecting the delivery method to confirm these findings Abbreviations • TOL • Trial Of Labor • CD • Cesarean Delivery • SD • Standard Deviation • IQR • Interquartile Range • IVF • In-Vitro-Fertilization • BMI • Body Mass Index (kg/m²) • Mg • Magnesium for neuroprotection • PPROM • Preterm Premature Rupture of Membranes • PE • Preeclampsia • HELLP • Hemolysis Elevated Liver Enzymes, Low Platelets • NRFHM • Non-Reassuring Fetal Heart Monitoring • BPD • Bronchopulmonary Dysplasia • IVH • Intraventricular Hemorrhage • NEC • Necrotizing Enterocolitis • PVL • Periventricular Leukomalacia • DIC • Disseminated Intravascular Coagulation Declarations Ethics approval and consent to participate All methods were conducted in compliance with applicable guidelines and regulations. This study adhered to the principles outlined in the Declaration of Helsinki. It was approved by the institutional review board (0284-08-TLV) which waived informed consent due to its retrospective design and anonymized data. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Corresponding author Itamar Gilboa, [email protected] Funding None Author Contribution IG, LH and ML conceived and designed the study; IG, DG, NZ, and BM participated in data acquisition; IG and DG performed data analysis; IG, YY, LH and ML interpreted data for the work; IG, YY, AL, EA, LH and ML drafted the article and all other co-authors revised it for important intellectual content; all authors gave final approval of the final version and agree to be accountable for all aspects of the work. Acknowledgements Not applicable. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Martin JA, Hamilton BE, Osterman M. Births in the united states, 2020. NCHS Data Brief. 2021;(418):1–8. Prediction and prevention of spontaneous preterm birth. ACOG practice bulletin, number 234. Obstet Gynecol. 2021;138(2):e65–90. Glass HC, Costarino AT, Stayer SA, Brett CM, Cladis F, Davis PJ. Outcomes for extremely premature infants. Anesth Analg. 2015;120(6):1337–51. Ohuma EO, Moller A-B, Bradley E, Chakwera S, et al. National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis. Lancet. 2023;402(10409):1261–71. Howson CP, Kinney MV, McDougall L, Lawn JE. Born Too Soon Preterm Birth Action Group. Born too soon: preterm birth matters. Reprod Health. 2013;10(Suppl 1):S1. Wood NS, Costeloe K, Gibson AT, et al. The EPICure study: associations and antecedents of neurological and developmental disability at 30 months of age following extremely preterm birth. Arch Dis Child Fetal Neonatal Ed. 2005;90(2):F134–40. Swamy GK, Ostbye T, Skjaerven R. Association of preterm birth with long-term survival, reproduction, and next-generation preterm birth. JAMA. 2008;299(12):1429–36. Crowley P, Chalmers I, Keirse MJ. The effects of corticosteroid administration before preterm delivery: an overview of the evidence from controlled trials. Br J Obstet Gynaecol. 1990;97(1):11–25. Costantine MM, Weiner SJ, Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Effects of antenatal exposure to magnesium sulfate on neuroprotection and mortality in preterm infants: a meta-analysis. Obstet Gynecol. 2009;114(2 Pt 1):354–64. Crowther CA, McKinlay CJD, Middleton P, Harding JE. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes. Cochrane Database Syst Rev. 2015;2015(7):CD003935. Malloy MH. Impact of cesarean section on neonatal mortality rates among very preterm infants in the United States, 2000–2003. Pediatrics. 2008;122(2):285–92. Jarde A, Feng YY, Viaje KA, Shah PS, McDonald SD. Vaginal birth vs caesarean section for extremely preterm vertex infants: a systematic review and meta-analyses. Arch Gynecol Obstet. 2020;301(2):447–58. Bottoms SF, Paul RH, Iams JD, et al. Obstetric determinants of neonatal survival: Influence of willingness to perform cesarean delivery on survival of extremely low-birth-weight infants. Am J Obstet Gynecol. 1997;176(5):960–6. Lucey JF, Rowan CA, Shiono P, et al. Fetal infants: the fate of 4172 infants with birth weights of 401 to 500 grams–the Vermont Oxford Network experience (1996–2000). Pediatrics. 2004;113(6):1559–66. Kuper SG, Sievert RA, Steele R, Biggio JR, Tita AT, Harper LM. Maternal and neonatal outcomes in indicated preterm births based on the intended mode of delivery. Obstet Gynecol. 2017;130(5):1143–51. Alfirevic Z, Milan SJ, Livio S. Caesarean section versus vaginal delivery for preterm birth in singletons. Cochrane Database Syst Rev. 2012;6(6):CD000078. Gluck O, Tairy D, Bar J, Barda G. The impact of mode of delivery on neonatal outcome in preterm births. J Matern Fetal Neonatal Med. 2021;34(8):1183–9. Zahedi-Spung LD, Raghuraman N, Macones GA, Cahill AG, Rosenbloom JI. Neonatal morbidity and mortality by mode of delivery in very preterm neonates. Am J Obstet Gynecol. 2022;226(1):114. .e1-114.e7 . Hiersch L, Shah PS, Khurshid F et al. Mode of delivery and neonatal outcomes in extremely preterm Vertex/nonVertex twins. Am J Obstet Gynecol. 2021;224(6):613.e1-613.e10. Thomas PE, Petersen SG, Gibbons K. The influence of mode of birth on neonatal survival and maternal outcomes at extreme prematurity: A retrospective cohort study. Aust N Z J Obstet Gynaecol. 2016;56(1):60–8. Običan SG, Small A, Smith D, Levin H, Drassinower D, Gyamfi-Bannerman C. Mode of delivery at periviability and early childhood neurodevelopment. Am J Obstet Gynecol. 2015;213(4):e5781–4. Werner EF, Han CS, Savitz DA, Goldshore M, Lipkind HS. Health outcomes for vaginal compared with cesarean delivery of appropriately grown preterm neonates. Obstet Gynecol. 2013;121(6):1195–200. Bauer J, Hentschel R, Zahradnik H, Karck U, Linderkamp O. Vaginal delivery and neonatal outcome in extremely-low-birth-weight infants below 26 weeks of gestational age. Am J Perinatol. 2003;20(4):181–8. Werner EF, Savitz DA, Janevic TM, et al. Mode of delivery and neonatal outcomes in preterm, small-for-gestational-age newborns. Obstet Gynecol. 2012;120(3):560–4. Bitas C, Onishi K, Saade G, Kawakita T. Neonatal and Maternal Outcomes at 22–28 Weeks of Gestation by Mode of Delivery. Obstet Gynecol. 2023. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978;92(4):529–34. Bell MJ, Ternberg JL, Feigin RD, et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg. 1978;187(1):1–7. Shennan AT, Dunn MS, Ohlsson A, Lennox K, Hoskins EM. Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. Pediatrics. 1988;82(4):527–32. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4885592","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":351131227,"identity":"91019880-3ef4-4477-bf75-dd61e78ba415","order_by":0,"name":"Itamar Gilboa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYBAC+QYog0+C+QCQkpAhqIWNDcaQYEsAaeEhRQuPAYgmQot889MNP/cw2LVJ93x+daPGgoeB/fDRDfhtYTO72fOMIblN5uw265xjQIfxpKXdIOAwsxs8BxiS2SRytxnnAJ0H9I4ZAS3s327+AWvJeWac848oLTxmt4G22AG1MD/ObSNKS07ZbZkDEglsMsfMmHP7JHjYCPlFvvn4tptvDtjY80s3P/6c861Ojp/98DG8WqBAIrEBFDVge4lQDgb2QMz8gVjVo2AUjIJRMLIAAJ0KP54q3hoaAAAAAElFTkSuQmCC","orcid":"","institution":"Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Israel","correspondingAuthor":true,"prefix":"","firstName":"Itamar","middleName":"","lastName":"Gilboa","suffix":""},{"id":351131228,"identity":"53b0388e-9d8d-480f-9af4-6ca68ea83ed2","order_by":1,"name":"Daniel Gabbai","email":"","orcid":"","institution":"Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Israel","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Gabbai","suffix":""},{"id":351131229,"identity":"3040a58a-19f7-406a-89c4-4907ff323610","order_by":2,"name":"Yariv Yogev","email":"","orcid":"","institution":"Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Israel","correspondingAuthor":false,"prefix":"","firstName":"Yariv","middleName":"","lastName":"Yogev","suffix":""},{"id":351131230,"identity":"76aab04a-01af-4dd9-9987-aad25cd23100","order_by":3,"name":"Anat Lavie","email":"","orcid":"","institution":"Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Israel","correspondingAuthor":false,"prefix":"","firstName":"Anat","middleName":"","lastName":"Lavie","suffix":""},{"id":351131231,"identity":"3a22dba7-764c-405c-b13a-9ddc6476b736","order_by":4,"name":"Emmanuel Attali","email":"","orcid":"","institution":"Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Israel","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Attali","suffix":""},{"id":351131232,"identity":"e74c34ce-b0e7-4a6d-b233-0501232e3aea","order_by":5,"name":"Noa Zaltz","email":"","orcid":"","institution":"Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Israel","correspondingAuthor":false,"prefix":"","firstName":"Noa","middleName":"","lastName":"Zaltz","suffix":""},{"id":351131233,"identity":"c1aa735e-7dea-409b-854d-90cfc138c1f4","order_by":6,"name":"Jacky Herzlich","email":"","orcid":"","institution":"Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Jacky","middleName":"","lastName":"Herzlich","suffix":""},{"id":351131234,"identity":"217a383e-3c57-4cf8-b51b-1921ab430c6a","order_by":7,"name":"Ben Melamed","email":"","orcid":"","institution":"Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Israel","correspondingAuthor":false,"prefix":"","firstName":"Ben","middleName":"","lastName":"Melamed","suffix":""},{"id":351131235,"identity":"94ab897f-7e39-444a-b670-cd27d14fc65b","order_by":8,"name":"Liran Hiersch","email":"","orcid":"","institution":"Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Israel","correspondingAuthor":false,"prefix":"","firstName":"Liran","middleName":"","lastName":"Hiersch","suffix":""},{"id":351131236,"identity":"44c50c88-aed7-4d86-9b1c-8c319fe99fc6","order_by":9,"name":"Michael Lavie","email":"","orcid":"","institution":"Lis Hospital for Women’s Health, Tel Aviv Sourasky Medical Center, Israel","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Lavie","suffix":""}],"badges":[],"createdAt":"2024-08-09 08:40:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4885592/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4885592/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66124538,"identity":"ff215920-b05e-4f68-b9c6-bfeec53b691d","added_by":"auto","created_at":"2024-10-08 02:36:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":19688,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4885592/v1/0be04a80f28074e174b5092b.png"},{"id":66126329,"identity":"c1db545c-48f2-48ae-89e0-495fd3d6897a","added_by":"auto","created_at":"2024-10-08 02:52:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1011885,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4885592/v1/8fffea57-b0af-4ffe-93de-a4dd562afc99.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Trial of Labor and Neonatal Outcomes in Extreme prematurity \u003c28 Weeks' Gestation ","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003ePreterm birth (PTB) is the leading cause of neonatal morbidity and mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), which are inversely related to gestational age at delivery (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In extreme PTB, commonly defined as birth\u0026thinsp;\u0026lt;\u0026thinsp;28 weeks of gestation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), neonatal mortality can reach up to 50% with similar rates of morbidity among survivors (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Therefore, efforts are invested in both preventing extreme prematurity and optimizing medical care in those cases.\u003c/p\u003e \u003cp\u003eWhile some interventions, such as the administration of antenatal corticosteroids and magnesium sulphate, have been shown to be beneficial in decreasing neonatal complications (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), the optimal mode of delivery (MOD) in cases of PTB\u0026thinsp;\u0026lt;\u0026thinsp;28 weeks of gestation remains controversial. Some studies suggest that in extreme prematurity, cesarean delivery (CD) is associated with reduced rates of neonatal mortality (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and improved long-term survival (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) in comparison to vaginal delivery. Other studies, however, reported no significant neonatal differences related to MOD of extreme prematurity (\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), while some reported an increased risk of neonatal morbidity with CD (\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNevertheless, most prior studies compared cases of CD with cases of successful vaginal delivery without taking into consideration a trial of labor (TOL). However, in cases of TOL, birth can be either vaginal or rather an emergent CD, which is usually performed in suboptimal conditions and can adversely affect perinatal outcome, and might underestimate the potential benefits of primary CD in those cases (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Other limitations of prior studies include a relatively small sample size (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), heterogeneity among groups with gestational age ranging up to 34 weeks (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), and failure to adjust for potential confounding factors such as the indication or etiology of PTB (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHence, our aim was to assess the optimal MOD for cases of extreme PTB occurring before 28 weeks of gestation, using an intention-to-treat approach. This was achieved by comparing outcomes between a TOL and planned CD without attempting labor.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eA retrospective cohort study of all patients who gave birth between 24\u003csup\u003e0/7\u003c/sup\u003e \u0026ndash; 27\u003csup\u003e6/7\u003c/sup\u003e weeks of gestation in a single university-affiliated tertiary medical center (2011\u0026ndash;2022). It was approved by the institutional review board (0284-08-TLV) which waived informed consent due to its retrospective design and anonymized data.\u003c/p\u003e \u003cp\u003eExclusion criteria included multiple gestations,and non-viable fetuses,. In our institute, at extreme prematurity patients are consulted regarding mode of delivery (MOD) and the choice of CD is given even in the lack of contraindication for trial of labor. The decision regarding MOD is then determined based on standard obstetrical indications, patients' preferences, and physicians' preferences. We included all qualifying pregnancies delivered during the study period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData source\u003c/h2\u003e \u003cp\u003eMaternal and neonatal data were obtained from the computerized medical records. We retrieved maternal and pregnancy data, including: maternal age, body mass index (BMI), parity, surgical history, gestational age (GA) at delivery, mode of conception, onset of labor, indication for CD, antepartum corticosteroids administration (considered only if patients received full course), administration of Magnesium sulphate (Mg) for neuroprotection, and pregnancy complications.\u003c/p\u003e \u003cp\u003eThe following data were collected from the neonatal records: Apgar score at 1 and 5 min, arterial blood PH, birthweight and neonatal complications: necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), mechanical ventilation, bronchopulmonary dysplasia (BPD), periventricular leukomalacia (PVL), and newborn death before discharge. Postnatal outcomes were recorded during hospitalization before discharge.\u003c/p\u003e \u003cp\u003eChorioamnionitis was defined based on clinical suspicion by obstetricians at the time of delivery. The diagnosis typically involved the presence of maternal fever of 38\u0026deg;C accompanied one of the following: fetal tachycardia (above 160 beats per minute), maternal leukocytosis\u0026thinsp;\u0026gt;\u0026thinsp;15,000 in the absence of corticosteriods, purulent fluid from the external os, and uterine sensitivity. In some cases, chorioamnionitis was confirmed post-delivery through positive cultures from the placenta (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePathologic blood flow was defined as absent or reversed end-diastolic flow in the umbilical artery or absent or reversed \"A-wave\" in the ductus venosus.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eExposure\u003c/h2\u003e \u003cp\u003eThe exposure of interest was trial of labor. Neonatal outcomes were compared between those with vertex presentation who opted for vaginal delivery (\u003cb\u003eTOL group)\u003c/b\u003e regardless of the eventual mode of delivery (vaginal/cesarean delivery) and those who opted for planned CD (\u003cb\u003eCD group\u003c/b\u003e). Patients with a-priori indication for CD (e.g. non-vertex presentation, placenta previa) were included in the CD group. Patients who opted a TOL and had eventually maternal or fetal indications for urgent CD during labor, were included in the TOL group, in an intention-to-treat approach.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe \u003cb\u003eprimary outcome\u003c/b\u003e was a composite adverse neonatal outcome, defined as one or more of the following: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) neonatal death prior to discharge; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) severe neurological injury, defined as grade 3 or 4 intraventricular hemorrhage (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eOverall composite outcome\u003c/b\u003e included any of the abovementioned or any of the following: (NEC) stage 2 or 3 (29), bronchopulmonary dysplasia (BPD) (30), periventricular leukomalacia (PVL), neonatal sepsis, disseminated intravascular coagulation (DIC), arterial blood PH\u0026thinsp;\u0026lt;\u0026thinsp;7.1, or mechanical ventilation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe categorical variables were presented as frequency and percentage. Normality of the continuous variables was tested using the Kolmogorov\u0026ndash;Smirnov test and given as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation if normally distributed or median and interquartile range if normality could not be assumed. Comparisons between the groups were performed with the Student t-test for normally distributed continuous variables and with the Mann-Whitney rank sum test for non-normally distributed continuous variables. The Chi-square and Fisher\u0026rsquo;s exact tests were used for comparing categorical variables.\u003c/p\u003e \u003cp\u003eA multivariable logistic regression model, controlling for variables found to be statistically different between groups with p\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in the univariate analysis, in addition to variables that were chosen a priori such as gestational age at birth, newborn birthweight, antepartum steroids, magnesium, and newborn sex, was used to identify variables independently associated with the study outcomes. Groups were analyzed according to intention to treat. Two distinct sub-analyses were conducted. The first focused on women experiencing spontaneous labor onset without maternal or neonatal delivery indications. The second analyzed women within the gestational age range of 25\u003csup\u003e0/7\u003c/sup\u003e to 27\u003csup\u003e6/7\u003c/sup\u003e weeks, considering the elevated mortality risk in newborns born before 25 weeks of gestation. All statistical analyses were performed using SPSS software (SPSS version 29, IBM, Chicago).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAmong 131,019 women delivering between 24\u003csup\u003e0/7\u003c/sup\u003e-27\u003csup\u003e6/7\u003c/sup\u003e weeks of gestation during the study period, 199 met the study criteria (Figure 1). The Trial of Labor (TOL) group comprised of 64 women (32.2%), among whom 5 (7.8%) eventually underwent urgent cesarean delivery (CD), with 4 (6.3%) due to non-reassuring fetal heart monitoring (NRFHM) and 1 (1.6%) due to placental abruption. The planned CD group comprised 135 women (67.8%), of whom 73 women (54.1%) had a contraindication for TOL. This included 67 cases (49.6%) with a fetus in a non-vertex presentation and 6 cases (4.4%) with placenta previa.\u003c/p\u003e\n\u003cp\u003eMaternal and obstetrical characteristics are delineated in Table 1. Within the TOL group, there were higher rates of delivery occurring between 24\u003csup\u003e0/7\u003c/sup\u003e-24\u003csup\u003e6/7\u003c/sup\u003e weeks of gestation and spontaneous onset of labor. Conversely, the planned CD group had higher rates of preeclampsia (PE)/Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) syndrome, as well as non-reassuring fetal heart monitoring (NRFHM) (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Baseline characteristics of the TOL and planned CD Groups.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOL group (n=64)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlanned \u0026nbsp;CD\u003c/strong\u003e \u003cstrong\u003egroup (n=135)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eMaternal age, mean (SD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e32.8 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e33.5 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.485\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e26.0 (24.5-27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e25.6 (24.5-26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.593\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 24\u003csup\u003e0/7\u003c/sup\u003e-24\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e16 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e17 (12.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 25\u003csup\u003e0/7\u003c/sup\u003e-25\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e11 (17.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e38 (28.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 26\u003csup\u003e0/7\u003c/sup\u003e-26\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e19 (29.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e35 (25.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.577\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 27\u003csup\u003e0/7\u003c/sup\u003e-27\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e18 (28.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e46 (34.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.401\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePre-gestational BMI, \u0026nbsp; \u0026nbsp; median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e21.8 (20.5-25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e23.0 (19.7-23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eIVF, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e12 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e33 (24.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.370\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eNulliparity, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e38 (59.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e64 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious CD, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e6 (9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e21 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eAntepartum steroids, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e43 (67.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e91 (67.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.919\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eMg, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e47 (73.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e83 (61.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eSpontaneous onset of labor, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e64 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e59 (43.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePPROM, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e22 (37.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e27 (27.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.175\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eUterine rupture, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e6 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePE/HELLP, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e20 (14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePlacental abruption, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e12 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e28 (20.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.743\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eChorioamnionitis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e7 (10.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e20 (14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.456\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePathological blood flow, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e7 (5.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eNRFHM, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e4 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e29 (21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eMeconium, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e10 (15.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e18 (13.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eNewborn weight, grams (mean ,SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e857 (189)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e818 (185)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.823\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eFemale sex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e25 (39.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e72 (53.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: IVF, in-vitro-fertilization; CD, cesarean delivery; BMI, body-mass-index (kg/m\u003csup\u003e2\u003c/sup\u003e); Mg, magnesium for neuroprotection; PPROM, preterm premature rupture of membranes; PE, preeclampsia; HELLP, hemolysis elevated liver enzymes, low platelets; NRFHM , non-reassuring fetal heart monitor; SD, standard deviation; IQR, interquartile range\u003c/p\u003e\n\u003cp\u003eTable 2 presents neonatal outcomes. Among the entire cohort, neonatal death occurred in 48 cases (24.2%), with no significant differences observed between the TOL and planned CD groups (19.0% vs. 26.7%, p=0.244). Similarly, there were no significant differences between the TOL and CD groups concerning the rates of primary (26.6% vs. 31.9%, p=0.448) and overall composite outcomes (85.9% vs. 90.4%, p=0.352). Furthermore, the rates of individual components of secondary outcomes and overall composite outcomes did not vary between the groups (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Comparison of neonatal outcomes in patients with a TOL and planned CD\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"557\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOL group (n=64)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlanned \u0026nbsp;CD\u003c/strong\u003e \u003cstrong\u003egroup (n=135)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003ePrimary composite outcome, n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e17 (26.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e43 (31.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.448\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eOverall composite outcome, n (%)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e55 (85.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e122 (90.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.352\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eDeath, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e12 (19.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e36 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.244\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003e5-min Apgar \u0026lt; 7, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e21 (32.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e52 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.435\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eUmbilical arterial PH\u0026lt;7.1, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e6 (9.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e6 (4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.172\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eMechanical ventilation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e45 (70.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e99 (73.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.656\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eBPD, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e32 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e68 (50.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.961\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eIVH, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e9 (14.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e15 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.550\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eNEC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e8 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e15 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003ePVL, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e5 (7.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e9 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.768\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eSepsis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e7 (10.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e15 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.971\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eDIC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e5 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.409\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations:; BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage (grade 3/4); NEC, necrotizing enterocolitis (stage 2/3); PVL, periventricular leukomalacia; DIC, disseminated intravascular coagulation; SD, standard deviation; IQR, interquartile range\u003c/p\u003e\n\u003cp\u003ea\u003cspan dir=\"LTR\"\u003e\u0026nbsp;Defined as one or more of the following: newborn death prior to discharge, severe neurological injury.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Defined as one or more of the following: newborn death prior to discharge, severe neurological injury, NEC (stage 2/3), BPD, PVL, mechanical ventilation, neonatal sepsis, arterial ph\u0026lt; 7.1, and DIC\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMultivariate analysis, adjusted for gestational age, newborn birthweight, gender, magnesium for neuroprotection, antepartum steroids, spontaneous onset of labor, uterine rupture, non-reassuring fetal heart rate, HELLP syndrome, and pathological blood flow, did not find significant differences between a TOL and CD.\u003c/p\u003e\n\u003cp\u003eIn order to determine the potential impact of TOL on neonatal outcomes, we conducted a sub-analysis, limited to pregnancies with spontaneous onset of labor. The TOL group consisted of 44 deliveries, while the CD group comprised 39 deliveries. Within the TOL group, one delivery (2.3%) required conversion to urgent CD. Notably, among the CD group, 92.3% had a predetermined indication for CD (non-cephalic presentation), while the remaining opted for CD without TOL.\u003c/p\u003e\n\u003cp\u003eMaternal and obstetrical characteristics were comparable between the groups (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Subgroup analysis - baseline characteristics of the TOL and planned CD groups with spontaneous onset of labor.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"538\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOL (n=44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlanned \u0026nbsp;CD\u003c/strong\u003e \u003cstrong\u003egroup (n=39)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eMaternal age, (mean ,SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e33.0 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e34.5 (6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.801\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003ePre- gestational BMI, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e21.8 (20.5-25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e23.0 (19.7-23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.593\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e26.0 (24.5-27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e25.6 (24.5-26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 24\u003csup\u003e0/7\u003c/sup\u003e-24\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e14 (31.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e9 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.375\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 25\u003csup\u003e0/7\u003c/sup\u003e-25\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e9 (20.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e10 (25.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.575\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 26\u003csup\u003e0/7\u003c/sup\u003e-26\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e11 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e10 (25.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.947\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 27\u003csup\u003e0/7\u003c/sup\u003e-27\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e10 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e10 (25.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.757\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eConception (IVF), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e7 (15.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e6 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.948\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eNulliparity, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e29 (65.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e18 (46.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious CD, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e5 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e5 (12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.839\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eAntepartum steroids, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e30 (68.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e26 (68.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eMg, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e32 (72.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e22 (57.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.158\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003ePPROM, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e15 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e11 (44.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.603\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eNon-vertex presentation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e36 (92.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003ePlacenta previa, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eMeconium, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e7 (15.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e3 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.251\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eNewborn weight, grams (mean ,SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e835 (202)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e847 (165)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.62383612662942%\" valign=\"top\"\u003e\n \u003cp\u003eFemale sex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e16 (36.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.042830540037244%\" valign=\"top\"\u003e\n \u003cp\u003e20 (51.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.29050279329609%\" valign=\"top\"\u003e\n \u003cp\u003e0.171\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: IVF, in-vitro-fertilization; CD, cesarean delivery; BMI, body-mass-index (kg/m\u003csup\u003e2\u003c/sup\u003e); Mg, magnesium for neuroprotection; PPROM, preterm premature rupture of membranes; \u0026nbsp;SD, standard deviation; IQR, interquartile range\u003c/p\u003e\n\u003cp\u003eSimilarly, rates of primary and overall composite outcomes were similar between the groups (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Subgroup analysis - neonatal outcomes of TOL and planned CD groups comparing only cases with spontaneous onset of labor.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"538\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOL group\u003c/strong\u003e (n=44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlanned \u0026nbsp;CD\u003c/strong\u003e \u003cstrong\u003egroup\u0026nbsp;\u003c/strong\u003e(n=39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003ePrimary composite outcome, n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e11 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e9 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.838\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eOverall composite outcome, n (%)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e39 (88.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e35 (89.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.871\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eDeath, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e10 (23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e7 (17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.554\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eApgar \u0026lt; 7 (5 min), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e17 (38.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e12 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.920\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eUmbilical arterial PH \u0026lt;7.1, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e5 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.122\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eMechanical ventilation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e31 (70.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e31 (79.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.345\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eBPD, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e24 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e25 (64.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.377\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eIVH, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e6 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e4 (10.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.637\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eNEC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e5 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e6 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.590\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003ePVL, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e4 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e3 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.819\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eSepsis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e3 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e5 (12.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003e0.355\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"49.07063197026022%\" valign=\"top\"\u003e\n \u003cp\u003eDIC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.33085501858736%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.267657992565056%\" valign=\"top\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage (grade 3/4); NEC, necrotizing enterocolitis (stage 2/3); PVL, periventricular leukomalacia; DIC, disseminated intravascular coagulation; SD, standard deviation; IQR, interquartile range\u003c/p\u003e\n\u003cp\u003ea\u003cspan\u003e\u0026nbsp;Defined as one or more of the following: newborn death prior to discharge, severe neurological injury.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Defined as one or more of the following: newborn death prior to discharge, severe neurological injury, NEC (stage 2/3), BPD, PVL, mechanical ventilation, neonatal sepsis, arterial ph\u0026lt; 7.1, and DIC\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the significant disparities in preterm birth rates within the gestational age range of 24\u003csup\u003e0/7\u003c/sup\u003e-24\u003csup\u003e6/7\u003c/sup\u003e weeks, we conducted a supplementary sub-analysis excluding this period and focusing on pregnancies within the range of 25\u003csup\u003e0/7\u003c/sup\u003e-27\u003csup\u003e6/7\u003c/sup\u003eweeks. Within this gestational age range, the TOL group experienced higher rates of magnesium treatment for neuroprotection and spontaneous onset of labor. Conversely, the CD group exhibited increased prevalance of NRFHM and PE/HELLP syndrome (Table 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Subgroup analysis - baseline characteristics of the TOL and planned CD groups\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ebetween\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e25\u003csup\u003e0/7\u003c/sup\u003e-27\u003csup\u003e6/7\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;weeks of gestation.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOL group (n=48)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlanned \u0026nbsp;CD\u003c/strong\u003e \u003cstrong\u003egroup (n=118)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eMaternal age, mean (SD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e32.6 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e33.2 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e26.5 (26.0-27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e26.4 (25.6-27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 25\u003csup\u003e0/7\u003c/sup\u003e-25\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e11 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e37 (31.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.277\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 26\u003csup\u003e0/7\u003c/sup\u003e-26\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e19 (39.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e35 (29.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eGestational age 27\u003csup\u003e0/7\u003c/sup\u003e-27\u003csup\u003e6/7\u003c/sup\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e18 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e46 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.859\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePre-gestational BMI, \u0026nbsp; \u0026nbsp; median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e21.7 (20.7-23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e22.5 (20.3-25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.531\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eIVF, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e9 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e29 (24.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eNulliparity, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e28 (58.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e56 (47.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.204\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePrevious CD, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e4 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e19 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.189\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eAntepartum steroids, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e35 (72.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e78 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.433\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eMg, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e37 (77.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e70 (59.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eSpontaneous onset of labor, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e48 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e45 (38.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePPROM, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e14 (31.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e25 (27.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.687\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eUterine rupture, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e4 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.193\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePE/HELLP, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e20 (16.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePlacental abruption, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e11 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e24 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eChorioamnionitis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e6 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e19 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.556\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003ePathological blood flow, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e7 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eNRFHM, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e4 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e28 (23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eMeconium, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e7 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e17 (14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.993\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eNewborn weight, grams (mean ,SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e922 (164)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e834 (190)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.99674267100977%\" valign=\"top\"\u003e\n \u003cp\u003eFemale sex, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e21 (43.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03257328990228%\" valign=\"top\"\u003e\n \u003cp\u003e63 (53.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.938110749185668%\" valign=\"top\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: IVF, in-vitro-fertilization; CD, cesarean delivery; BMI, body-mass-index (kg/m\u003csup\u003e2\u003c/sup\u003e); Mg, magnesium for neuroprotection; PPROM, preterm premature rupture of membranes; PE, preeclampsia; HELLP, hemolysis elevated liver enzymes, low platelets; NRFHM , non-reassuring fetal heart monitor; SD, standard deviation; IQR, interquartile range\u003c/p\u003e\n\u003cp\u003eTable 6 delineates neonatal outcomes\u0026nbsp;in patients with a TOL and planned CD between 25\u003csup\u003e0/7\u003c/sup\u003e-27\u003csup\u003e6/7\u003c/sup\u003e weeks of gestation. Notably, no significant difference were found between the groups regarding primary and overall composite outcomes. However, the TOL group displayed a trend towards lower rates of neonatal mortality compared to the CD group, although statistical significance was not achieved (10.4% vs. 22.9%, p=0.065).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. \u0026nbsp;Subgroup analysis - comparison of neonatal outcomes in patients with a TOL and planned CD between 25\u003csup\u003e0/7\u003c/sup\u003e-27\u003csup\u003e6/7\u003c/sup\u003e weeks of gestation\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"557\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOL group (n=48)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlanned \u0026nbsp;CD\u003c/strong\u003e \u003cstrong\u003egroup (n=118)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003ePrimary composite outcome, n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e9 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e33 (28.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eOverall composite outcome, n (%)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e40 (83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e105 (89.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.321\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eDeath, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e5 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e27 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003e5-min Apgar \u0026lt; 7, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e16 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e41 (34.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.862\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eUmbilical arterial PH \u0026lt;7.1, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e3 6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e5 (4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.583\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eMechanical ventilation, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e33 (68.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e86 (72.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.592\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eBPD, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e27 (56.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e61 (51.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.594\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eIVH, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e6 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e11 (9.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.540\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eNEC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e7 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e12 (10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003ePVL, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e4 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e8 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.726\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eSepsis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e5 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e12 (10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.962\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.064748201438846%\" valign=\"top\"\u003e\n \u003cp\u003eDIC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.906474820143885%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.323741007194243%\" valign=\"top\"\u003e\n \u003cp\u003e5 (4.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.705035971223023%\" valign=\"top\"\u003e\n \u003cp\u003e0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations:; BPD, bronchopulmonary dysplasia; IVH, intraventricular hemorrhage (grade 3/4); NEC, necrotizing enterocolitis (stage 2/3); PVL, periventricular leukomalacia; DIC, disseminated intravascular coagulation; SD, standard deviation; IQR, interquartile range\u003c/p\u003e\n\u003cp\u003ea\u003cspan dir=\"LTR\"\u003e\u0026nbsp;Defined as one or more of the following: newborn death prior to discharge, severe neurological injury.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Defined as one or more of the following: newborn death prior to discharge, severe neurological injury, NEC (stage 2/3), BPD, PVL, mechanical ventilation, neonatal sepsis, arterial ph\u0026lt; 7.1, and DIC\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cstrong\u003ePrincipal Findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the current study we aimed to determine the effect of MOD on neonatal outcome in cases of singleton pregnancies delivered at \u0026lt;28 weeks of gestation. Our main findings were: While the rates of neonatal death did not reach statistical significance, it is possible that this outcome reflects the tendency for patients with urgent maternal or neonatal indications to undergo cesarean delivery. This could potentially account for the observed higher mortality rates in the CD group; 2) The rate of short term neonatal morbidity was not significantly different between TOL and CD groups; 3) In deliveries where a TOL was pursued, the majority of women attained vaginal delivery with relatively few cases needed an urgent CD. \u0026nbsp;In addition, in those with spontaneous onset of labor, TOL was not associated with increased risk of neonatal morbidity compared to planned CD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults in the Context of What is Known\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMode of delivery for early preterm neonates has been a source of significant debate, a controversy that is mirrored in our study outcomes. Our study did not find significant differences in neonatal mortality and morbidity when comparing mode of delivery (MOD) within the gestational age range of 240/7-276/7 weeks.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe question regarding optimal mode of delivery in early preterm neonates was recently addressed by two separate studies (18,25). In one study, the authors did not find increased neonatal morbidity or mortality in vaginal delivery compared to CD (18), while in the other study, the authors found that vaginal delivery was associated with increased risk for neonatal morbidity and mortality in cephalic fetuses, with the opposite results for non-cephalic fetuses (25). However, these studies were mainly limited by failure to adjust for potential confounding factors such as the indication of an early delivery. In addition, in both studies there is a lack of data concerning patients who had initially a trial of vaginal delivery and were taken for CD due to fetal or maternal indications, which in turn could have biased the results\u003c/p\u003e\n\u003cp\u003ePrevious studies showed potential link between cesarean deliveries (CD) and an increased risk for adverse neonatal outcomes. Malloy et al., noted a decreased risk of neonatal death among infants born through CD at 22-25 weeks of gestation (11). Similarly, Jarde et al. performed a meta-analysis encompassing singleton pregnancies below 28 weeks and found that cesarean deliveries were significantly correlated with reduced adjusted odds of death in those infants with vertex presentation (12).\u003c/p\u003e\n\u003cp\u003eConversely, other investigations have indicated that the mode of delivery might not have a substantial impact on neonatal outcomes (15\u0026ndash;21). Zahedi-Spung et al. recently conducted a retrospective study involving singleton pregnancies delivered between 22 to 29 weeks\u0026rsquo; gestation (18). Although cesarean delivery was linked with decreased risk for death in the delivery room or within 24 hours after birth, it did not lead to an overall improvement in morbidity or mortality. This also aligns with the findings of a large retrospective study by Hiersch et al. who explored the association of MOD and neonatal outcomes in twin pregnancies between 240/7-276/7 weeks of gestation and did not observed and significant differences between those who had a TOL and those who underwent cesarean delivery (19). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn contrast, Bauer et al. reported an elevated risk of neonatal morbidity associated with CD compared to vaginal delivery in preterm births \u0026lt; 26 weeks of gestation (23). They also observed higher survival rates among newborns delivered vaginally. Additionally, Werner et al. suggested that neonatal mortality rates were comparable among newborns born between 24 and 34 weeks of gestation, while noting elevated rates of neonatal morbidity in the cesarean delivery group (22,24). More recently, Bitas et al. conducted an extensive study assessing mode of delivery and neonatal outcomes among 22-28 weeks of gestation (25). Their findings indicated that CD posed an increased risk for neonatal death in cephalic presentations compared to vaginal delivery (VD), while non-cephalic presentations showed higher risks for neonatal mortality and morbidity.\u003c/p\u003e\n\u003cp\u003eIn a recent meta-analysis led by Demertzidou et al., 27 retrospective studies on singleton pregnancies were examined to assess how the mode of delivery influences the perinatal outcomes of fetuses born before 32 weeks\u0026apos; gestation. The findings revealed that in infants delivered before 28 weeks, vaginal delivery notably heightened the risk of neonatal death within 28 days post-birth, regardless of presentation, particularly with breech presentation. However, when assessing survival before discharge, there was no discernible difference between the delivery groups (31).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical and research implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, there is a lack of clear evidence regarding the optimal MOD for extremely preterm births. It appears that, ultimately, mortality and morbidity in this vulnerable group born before 28 weeks\u0026rsquo; gestation are predominantly determined by their extreme prematurity. This may overshadow any minor variations linked to the mode of delivery, with no definitive neonatal benefit identified when contemplating MOD in extremely premature infants. While the lack of differences between groups could potentially be attributed to insufficient power, we believe this is less likely given that the point estimates were similar overall between the study and control groups. We hope that the findings of this study can assist caregivers when discussing the mode of delivery in cases of extreme preterm deliveries. Furthermore, they underscore the impact of extreme prematurity, highlighting the need for continued research to better understand the complex factors influencing neonatal outcomes in this population. It is noteworthy that although this study did not assess maternal outcomes or long-term infant and child outcomes, it revealed no significant neonatal benefit associated with cesarean delivery at this gestational age. However, it emphasizes the pivotal role of individualized decision-making in clinical practice. Patient preferences and future pregnancy plans are paramount considerations in guiding clinical decisions. This recommendation recognizes the multifaceted nature of clinical scenarios and highlights the importance of patient-centered care, which encompasses thoughtful consideration of maternal outcomes and further future evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study boasts several noteworthy strengths. First, it had a specific focus on a highly distinct cohort of early preterm infants born between 240/7-276/7 weeks of gestation, which sets it apart from the majority of prior studies that primarily concentrated on infants with gestational ages below 34 weeks. Furthermore, while most prior studies concluded their results based on the actual mode of delivery, our study proposed a different perspective in which we included patients who had a vaginal trial of labor, whether they delivered eventually vaginally or were taken to cesarean delivery, to those who did not have a vaginal trial of labor, in an intention to treat approach, which assist to refine results and to negate possible confounders.. In addition, another significant advantage of our study lies in the detailed comparison we conducted between spontaneous VD and primary indication for CD. This sub-analysis allowed us to mitigate the influence of other variables that could potentially affect neonatal outcomes, particularly scenarios where deliveries commenced as vaginal but then required an immediate transition to cesarean delivery, due to medical indications.\u003c/p\u003e\n\u003cp\u003eHowever, our study has several limitations. First, its retrospective design poses inherent constraints in terms of data collection and potential biases, in which we tried to overcome, and it should be taken into account when interpreting the results of our study. Furthermore, it should be noted that to be adequately powered (80%) to compare the study group with the control group, we will require approximately 720 patients in each group.\u003c/p\u003e\n\u003cp\u003eAdditionally, there was significant variation in presentation among our groups. The majority of newborns delivered via cesarean delivery, were not in cephalic presentation, whereas fetuses in the TOL were in cephalic presentation, contributing to heterogeneity. Moreover, in most cases, women with indications for early delivery within this gestational age range due to conditions such as PE/HELLP syndrome, or NRFHM, undergo CD without attempting a TOL. Although several indications for immediate delivery were included in our analysis, since it was not powered, they may have additional impact in which we could not demonstrate in our results. \u0026nbsp;Consequently, our findings warrant caution due to this diversity within our study groups.\u003c/p\u003e\n\u003cp\u003eIt is worth noting that the cohort spans from 2011 to 2023, and neonatal mortality rates may have varied over this period. However, despite potential fluctuations, neonatal mortality rates remained consistent, estimated at around 24% for the gestational age range studied annually.\u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study observed no disparity in the risk of adverse neonatal outcomes between individuals who pursued a trial of labor and those who underwent planned cesarean delivery among singleton early preterm births between 24 and 28 weeks of gestation. It is conceivable that extreme prematurity plays a pivotal role in determining neonatal outcomes within these cohorts. Moreover, our study implies that women who opt for a trial of labor have favorable prospects of achieving vaginal delivery, particularly given the relatively low rates of urgent cesarean deliveries. Nevertheless, it is imperative to interpret these findings judiciously due to the aforementioned limitations. Future prospective studies should validate these results and gather information on the reasons behind selecting the delivery method to confirm these findings\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; TOL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Trial Of Labor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; CD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Cesarean Delivery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; SD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Standard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; IQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Interquartile Range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; IVF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; In-Vitro-Fertilization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Body Mass Index (kg/m\u0026sup2;)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; Mg\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Magnesium for neuroprotection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PPROM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Preterm Premature Rupture of Membranes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Preeclampsia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; HELLP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Hemolysis Elevated Liver Enzymes, Low Platelets\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; NRFHM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Non-Reassuring Fetal Heart Monitoring\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; BPD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Bronchopulmonary Dysplasia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; IVH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Intraventricular Hemorrhage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; NEC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Necrotizing Enterocolitis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; PVL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Periventricular Leukomalacia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026bull; DIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e\u0026bull; Disseminated Intravascular Coagulation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e All methods were conducted in compliance with applicable guidelines and regulations. This study adhered to the principles outlined in the Declaration of Helsinki. It was approved by the institutional review board (0284-08-TLV) which waived informed consent due to its retrospective design and anonymized data.\u003c/p\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003ch2\u003eCorresponding author\u003c/h2\u003e \u003cp\u003eItamar Gilboa, [email protected]\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eIG, LH and ML conceived and designed the study; IG, DG, NZ, and BM participated in data acquisition; IG and DG performed data analysis; IG, YY, LH and ML interpreted data for the work; IG, YY, AL, EA, LH and ML drafted the article and all other co-authors revised it for important intellectual content; all authors gave final approval of the final version and agree to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMartin JA, Hamilton BE, Osterman M. Births in the united states, 2020. NCHS Data Brief. 2021;(418):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrediction and prevention of spontaneous preterm birth. ACOG practice bulletin, number 234. Obstet Gynecol. 2021;138(2):e65\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlass HC, Costarino AT, Stayer SA, Brett CM, Cladis F, Davis PJ. Outcomes for extremely premature infants. Anesth Analg. 2015;120(6):1337\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhuma EO, Moller A-B, Bradley E, Chakwera S, et al. National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis. Lancet. 2023;402(10409):1261\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHowson CP, Kinney MV, McDougall L, Lawn JE. Born Too Soon Preterm Birth Action Group. Born too soon: preterm birth matters. Reprod Health. 2013;10(Suppl 1):S1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWood NS, Costeloe K, Gibson AT, et al. The EPICure study: associations and antecedents of neurological and developmental disability at 30 months of age following extremely preterm birth. Arch Dis Child Fetal Neonatal Ed. 2005;90(2):F134\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwamy GK, Ostbye T, Skjaerven R. Association of preterm birth with long-term survival, reproduction, and next-generation preterm birth. JAMA. 2008;299(12):1429\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrowley P, Chalmers I, Keirse MJ. The effects of corticosteroid administration before preterm delivery: an overview of the evidence from controlled trials. Br J Obstet Gynaecol. 1990;97(1):11\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCostantine MM, Weiner SJ, Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Effects of antenatal exposure to magnesium sulfate on neuroprotection and mortality in preterm infants: a meta-analysis. Obstet Gynecol. 2009;114(2 Pt 1):354\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrowther CA, McKinlay CJD, Middleton P, Harding JE. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes. Cochrane Database Syst Rev. 2015;2015(7):CD003935.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalloy MH. Impact of cesarean section on neonatal mortality rates among very preterm infants in the United States, 2000\u0026ndash;2003. Pediatrics. 2008;122(2):285\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJarde A, Feng YY, Viaje KA, Shah PS, McDonald SD. Vaginal birth vs caesarean section for extremely preterm vertex infants: a systematic review and meta-analyses. Arch Gynecol Obstet. 2020;301(2):447\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBottoms SF, Paul RH, Iams JD, et al. Obstetric determinants of neonatal survival: Influence of willingness to perform cesarean delivery on survival of extremely low-birth-weight infants. Am J Obstet Gynecol. 1997;176(5):960\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLucey JF, Rowan CA, Shiono P, et al. Fetal infants: the fate of 4172 infants with birth weights of 401 to 500 grams\u0026ndash;the Vermont Oxford Network experience (1996\u0026ndash;2000). Pediatrics. 2004;113(6):1559\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuper SG, Sievert RA, Steele R, Biggio JR, Tita AT, Harper LM. Maternal and neonatal outcomes in indicated preterm births based on the intended mode of delivery. Obstet Gynecol. 2017;130(5):1143\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlfirevic Z, Milan SJ, Livio S. Caesarean section versus vaginal delivery for preterm birth in singletons. Cochrane Database Syst Rev. 2012;6(6):CD000078.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGluck O, Tairy D, Bar J, Barda G. The impact of mode of delivery on neonatal outcome in preterm births. J Matern Fetal Neonatal Med. 2021;34(8):1183\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZahedi-Spung LD, Raghuraman N, Macones GA, Cahill AG, Rosenbloom JI. Neonatal morbidity and mortality by mode of delivery in very preterm neonates. Am J Obstet Gynecol. 2022;226(1):114. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.e1-114.e7\u003c/span\u003e\u003cspan address=\"http://.e1-114.e7\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiersch L, Shah PS, Khurshid F et al. Mode of delivery and neonatal outcomes in extremely preterm Vertex/nonVertex twins. Am J Obstet Gynecol. 2021;224(6):613.e1-613.e10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas PE, Petersen SG, Gibbons K. The influence of mode of birth on neonatal survival and maternal outcomes at extreme prematurity: A retrospective cohort study. Aust N Z J Obstet Gynaecol. 2016;56(1):60\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObičan SG, Small A, Smith D, Levin H, Drassinower D, Gyamfi-Bannerman C. Mode of delivery at periviability and early childhood neurodevelopment. Am J Obstet Gynecol. 2015;213(4):e5781\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWerner EF, Han CS, Savitz DA, Goldshore M, Lipkind HS. Health outcomes for vaginal compared with cesarean delivery of appropriately grown preterm neonates. Obstet Gynecol. 2013;121(6):1195\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauer J, Hentschel R, Zahradnik H, Karck U, Linderkamp O. Vaginal delivery and neonatal outcome in extremely-low-birth-weight infants below 26 weeks of gestational age. Am J Perinatol. 2003;20(4):181\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWerner EF, Savitz DA, Janevic TM, et al. Mode of delivery and neonatal outcomes in preterm, small-for-gestational-age newborns. Obstet Gynecol. 2012;120(3):560\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBitas C, Onishi K, Saade G, Kawakita T. Neonatal and Maternal Outcomes at 22\u0026ndash;28 Weeks of Gestation by Mode of Delivery. Obstet Gynecol. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePapile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978;92(4):529\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBell MJ, Ternberg JL, Feigin RD, et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg. 1978;187(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShennan AT, Dunn MS, Ohlsson A, Lennox K, Hoskins EM. Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period. Pediatrics. 1988;82(4):527\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cesarean delivery, mode of delivery, neonatal morbidity, neonatal mortality, preterm delivery, extreme preterm birth","lastPublishedDoi":"10.21203/rs.3.rs-4885592/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4885592/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBACKGROUND\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe optimal mode of delivery for extremely preterm infants remains a subject of debate, particularly concerning the potential benefits of planned cesarean delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOBJECTIVE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to compare adverse neonatal outcomes between planned cesarean delivery and a trial of labor for singleton infants born before 28 weeks of gestation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTUDY DESIGN\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a retrospective cohort study of all singleton pregnancies delivered between 24\u003csup\u003e0/7\u003c/sup\u003e and 27\u003csup\u003e6/7\u003c/sup\u003e weeks of gestation at a single university-affiliated tertiary medical center. Patients were categorized into two groups: patients who opted a trial of vaginal delivery (TOL group) and those who had planned cesarean delivery (CD group). The primary outcome included neonatal death before discharge and severe neurological injury. Postnatal outcomes were recorded during hospitalization before discharge, and data were analyzed using an intention-to-treat analysis. Additional sub-analyses included women with spontaneous onset of labor without maternal or neonatal delivery indications and those within the gestational age range of 25\u003csup\u003e0/7\u003c/sup\u003e to 27\u003csup\u003e6/7\u003c/sup\u003e weeks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRESULTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 199 patients were eligible for inclusion: 64 opted a trial of vaginal delivery (TOL group), while 135 underwent planned cesarean delivery (CD group). Within the TOL group, there was a higher incidence of delivery at 24\u003csup\u003e0/7\u003c/sup\u003e- 24\u003csup\u003e6/7\u003c/sup\u003e weeks of gestation. Five women (7.8%) in the TOL group underwent intrapartum urgent CD. No disparities in the rates of primary or overall composite outcomes were observed between the TOL and CD groups (26.6% vs. 31.9%, p = 0.448 and 85.9% vs. 90.4%, p = 0.352, respectively). Adjusted multivariate analysis did not find significance between a trial of labor or planned cesarean delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONCLUSIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn extreme preterm births between 24–28 weeks of gestation no difference was found for the risk for adverse neonatal outcomes between those who had a trial of labor and those who underwent planned cesarean delivery.\u003c/p\u003e","manuscriptTitle":"Trial of Labor and Neonatal Outcomes in Extreme prematurity \u0026lt;28 Weeks' Gestation ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-08 02:36:01","doi":"10.21203/rs.3.rs-4885592/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"47184a61-c3d9-4a10-b4cc-5094eb2f940c","owner":[],"postedDate":"October 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-08T02:36:04+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-08 02:36:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4885592","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4885592","identity":"rs-4885592","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}