Induction-to-delivery time and neonatal resuscitation after cesarean delivery under general anesthesia: a multicenter retrospective cohort study

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Among potential contributors, the induction-to-delivery (ID) time—defined as the interval from the administration of general anesthetic agents to fetal expulsion—has emerged as a key and potentially modifiable factor. This study aimed to assess the relationship between ID time and the need for neonatal resuscitation during GA cesarean delivery, and to identify perioperative and maternal factors associated with increased resuscitation risk. Methods: A multicenter retrospective study was conducted among women with singleton pregnancies who underwent cesarean delivery under GA for pregnancy termination. Baseline maternal, anesthetic, and neonatal variables were collected. Categorical variables were analyzed using the Chi-square test, and continuous variables using the Wilcoxon rank-sum test. Univariable and multivariable logistic regression models were applied to identify independent risk factors for neonatal resuscitation, and a restricted cubic spline (RCS) model was used to evaluate the relationship between ID time and the probability of resuscitation. Results: A total of 1,523 cases were included; 212 neonates (13.9%) required resuscitation. Prolonged ID time was independently associated with an increased likelihood of neonatal resuscitation (OR = 1.04 per minute; 95% CI 1.01–1.06, p = 0.003). Additional predictors included gestational age < 34 weeks (OR = 17.11, 95% CI 10.49–28.17), gestational age 34–37 weeks (OR = 3.59, 95% CI 2.47–5.26), American Society of Anesthesiologists Physical Status III–IV (OR = 1.82, 95% CI 1.13–2.88), and anesthetic regimens involving propofol + sevoflurane (OR = 1.94, 95% CI 1.09–3.34) or mixed agents (OR = 8.86, 95% CI 4.55–17.45) compared with propofol + remifentanil. RCS analysis showed a nonlinear positive association between ID time and the probability of neonatal resuscitation. Conclusion: Prolonged ID time under GA constitutes a modifiable risk factor for neonatal resuscitation. Shortening ID time may help improve neonatal outcomes. Clinical trial number: not applicable. general anesthesia cesarean delivery induction-to-delivery time neonatal resuscitation risk factors Figures Figure 1 Figure 2 Introduction With the global rise in cesarean delivery rates, general anesthesia (GA) continues to play a crucial role in obstetric practice, particularly for emergency procedures, contraindications to neuraxial anesthesia, or maternal medical conditions precluding regional techniques [1,2]. Although advancements in anesthetic agents, airway management, and perinatal care have substantially improved safety, neonatal outcomes following cesarean section under GA remain less favorable compared with those under neuraxial anesthesia. Reported adverse outcomes include lower Apgar scores, increased need for resuscitation, and higher neonatal intensive care unit (NICU) admission rates [3,4]. Given that compromised neonatal condition at birth under GA frequently necessitates timely and guideline‑concordant resuscitation, contemporary neonatal life support recommendations highlight the need for rapid assessment and intervention to optimize early postnatal stabilization in this high‑risk population [5,6]. For anesthesiologists, obstetricians, and neonatal teams, understanding modifiable contributors to these outcomes is of direct clinical relevance. Among the factors influencing neonatal well-being under GA, the interval between anesthesia induction and fetal delivery—referred to as the induction-to-delivery (ID) time—has drawn particular attention as a potentially modifiable determinant. Shorter ID intervals are believed to limit fetal exposure to anesthetic agents and reduce the risk of hypoxia or acidosis [7]. Conversely, prolonged ID time has been associated with depressed neonatal condition, evidenced by lower Apgar scores and increased requirements for resuscitation or NICU care in both preterm and non-elective cesarean deliveries [8,9]. Studies conducted under spinal anesthesia further support this relationship, indicating that extended anesthesia-to-delivery intervals are linked to significant reductions in umbilical arterial pH and higher incidences of neonatal acidosis [10]. However, most existing evidence is derived from regional anesthesia settings, and data specific to GA remain scarce. Considering that GA is still required for patients with contraindications to neuraxial anesthesia or urgent obstetric conditions, understanding its unique risk profile is clinically important. Therefore, the present study aimed to clarify the association between ID time and neonatal resuscitation during cesarean delivery under GA in a contemporary multicenter cohort. In addition, perioperative and maternal factors contributing to prolonged ID time and adverse neonatal outcomes were analyzed using multivariable modeling to provide evidence for optimizing anesthetic strategies and intraoperative coordination in high-risk obstetric populations. Methods Study design and patient selection This multicenter retrospective cohort study collected data from January 2018 to June 2023 at four tertiary medical centers in China: Qilu Hospital of Shandong University, Shandong Provincial Hospital, First People’s Hospital of Lianyungang, and Binzhou Medical University Hospital. Inclusion criteria comprised patients with singleton pregnancies who underwent cesarean delivery under GA for pregnancy termination. Exclusion criteria included incomplete medical records or unclear diagnoses related to the cesarean delivery indication. Baseline characteristics and anesthesia management Maternal characteristics recorded included age, parity, body mass index (BMI), gestational age at delivery, gestational hypertension, gestational diabetes mellitus, autoimmune disease, anemia (hemoglobin < 110 g/L), premature rupture of membranes, polyhydramnios, oligohydramnios, fetal nuchal cord, previous cesarean delivery, and antenatal dexamethasone treatment. Fetal factors included presentation (cephalic vs non-cephalic), and indications for GA (placenta previa, coagulation disturbances, spine malformation, or other causes). Preoperative physical status was classified according to the American Society of Anesthesiologists (ASA). GA was induced intravenously based on institutional protocols using one of the following regimens: propofol + remifentanil, propofol + esketamine, propofol + sevoflurane, or etomidate + fentanyl, each combined with a neuromuscular blocking agent to facilitate tracheal intubation. Anesthetic drug selection, dosage, and maintenance were determined by attending anesthesiologists according to maternal condition and surgical requirements. Standard intraoperative monitoring and obstetric anesthesia management were uniformly applied. Neonatal variables collected included anesthesia ID time, meconium-stained amniotic fluid, birth weight, Apgar scores at 1, 5, and 10 minutes, need for resuscitation (defined as tracheal intubation or positive pressure ventilation via facemask), and NICU admission. Endpoints The primary endpoint was to identify clinical factors associated with neonatal resuscitation following GA cesarean delivery. Neonatal resuscitation was initiated when the newborn exhibited no spontaneous respiration, heart rate < 100 bpm, 1-minute Apgar score < 7, decreased tone, or respiratory depression, particularly in cases of maternal anesthetic exposure or suspected uteroplacental hypoperfusion [9,10]. Statistical analysis Baseline characteristics were described using frequencies (%) or medians with interquartile ranges. Categorical variables were compared using the chi-square test, and continuous variables using the Wilcoxon rank-sum test. Univariable logistic regression was first performed to identify potential factors associated with neonatal resuscitation. Variables with p < 0.10 were entered into a multivariate logistic regression model using backward stepwise elimination. Results were reported as odds ratio (OR) with 95% confidence intervals (CIs). The relationship between ID time and the probability of neonatal resuscitation was visualized using restricted cubic spline (RCS) models to capture potential nonlinear associations. All statistical analyses were conducted using R software (version 4.5.1; R Foundation for Statistical Computing, Vienna, Austria). Two-sided p < 0.05 was considered statistically significant. Results The study flowchart is shown in Fig. 1 . A total of 1,523 patients who underwent cesarean delivery under GA were included in the analysis. Based on neonatal outcomes, 1,311 neonates (86.1%) did not require resuscitation, while 212 neonates (13.9%) underwent resuscitation. Comparison of maternal and perinatal characteristics Table 1 summarizes baseline maternal and obstetric characteristics. Compared with the non-resuscitation group, neonates who required resuscitation were more frequently born to mothers with: parity ≥ 1 (77.8% vs 65.8%, p = 0.001), gestational hypertension (20.8% vs 9.6%, p < 0.001), gestational diabetes mellitus (17.9% vs 12.4%, p = 0.037), previous cesarean delivery (67.9% vs 56.8%, p = 0.003), and antenatal dexamethasone exposure (41.5% vs 25.2%, p < 0.001). The distribution of gestational age differed significantly between groups, with higher proportions of preterm births at < 34 weeks (30.2% vs 3.8%) and 34–37 weeks (43.9% vs 28.3%) in the resuscitation group (p < 0.001). In addition, the non-cephalic presentation and ASA physical status III–IV were more frequent among resuscitated neonates (p < 0.001 for both). Table 1 Comparison of pre-delivery characteristics Characteristics Total (n = 1523) No resuscitation (n = 1311) Resuscitation (n = 212) p value ID time (min) 10 (7–13) 9 (7–13) 11 (8–19) < 0.001 Age (year) 0.114 < 35 1127 (74.0) 980 (74.8) 147 (69.3) ≥ 35 396 (26.0) 331 (25.2) 65 (30.7) Parity 0.001 0 495 (32.5) 448 (34.2) 47 (22.2) ≥ 1 1028 (67.5) 863 (65.8) 165 (77.8) BMI (kg m − 2 ) 0.251 < 28 749 (49.2) 653 (49.8) 96 (45.3) ≥ 28 774 (50.8) 658 (50.2) 116 (54.7) Obstetric complications Gestational hypertension 170 (11.2) 126 (9.6) 44 (20.8) < 0.001 Gestational diabetes mellitus 201 (13.2) 163 (12.4) 38 (17.9) 0.037 Autoimmune disease 72 (4.7) 58 (4.4) 14 (6.6) 0.225 Anemia 785 (51.5) 677 (51.6) 108 (50.9) 0.909 Premature rupture of membranes 99 (6.5) 82 (6.3) 17 (8.0) 0.414 Polyhydramnios 48 (3.2) 40 (3.1) 8 (3.8) 0.729 Oligohydramnios 95 (6.2) 85 (6.5) 10 (4.7) 0.404 Fetal nuchal cord 274 (18.0) 244 (18.6) 30 (14.2) 0.141 Previous cesarean delivery 889 (58.4) 745 (56.8) 144 (67.9) 0.003 Dexamethasone treatment before delivery 418 (27.4) 330 (25.2) 88 (41.5) < 0.001 Fetal presentation 0.002 Cephalic 1359 (89.2) 1183 (90.2) 176 (83.0) Non-cephalic 164 (10.8) 128 (9.8) 36 (17.0) Labor duration (weeks) < 0.001 < 34 114 (7.5) 50 (3.8) 64 (30.2) 34–37 464 (30.5) 371 (28.3) 93 (43.9) ≥ 37 945 (62.0) 890 (67.9) 55 (25.9) Reasons for GA < 0.001 Placenta previa 509 (33.4) 416 (31.7) 93 (43.9) Coagulation disturbances 644 (42.3) 589 (44.9) 55 (25.9) Spine malformation 124 (8.1) 115 (8.8) 9 (4.2) Others 246 (16.2) 191 (14.6) 55 (25.9) ASA physical status classification < 0.001 I and II 1279 (84.0) 1138 (86.8) 141 (66.5) III and IV 244 (16.0) 173 (13.2) 71 (33.5) GA regimen < 0.001 Propofol + remifentanil + muscle relaxant 1095 (71.9) 975 (74.4) 120 (56.6) Propofol + esketamine + muscle relaxant 152 (10.0) 139 (10.6) 13 (6.1) Propofol + sevoflurane + muscle relaxant 116 (7.6) 93 (7.1) 23 (10.8) Etomidate + fentanyl + muscle relaxant 94 (6.2) 82 (6.3) 12 (5.7) Others 66 (4.3) 22 (1.7) 44 (20.8) Values are median (interquartile range) or n (%). BMI, body mass index; ASA, American Society of Anesthesiologists; GA, general anesthesia; ID, incision to delivery. Comparison of neonatal outcomes Perinatal and neonatal outcomes are detailed in Table 2 . Compared with neonates not requiring resuscitation, those in the resuscitation group had: lower median birth weights (2500 g [1993–2955] vs 3100 g [2750–3500], p < 0.001); markedly lower 1-minute Apgar scores (Apgar 0–7: 36.3% vs 0.2%, p < 0.001); and higher NICU admission rates (90.6% vs 22.1%, p < 0.001). Table 2 Comparisons of perinatal neonatal outcomes Characteristics Total (n = 1523) No resuscitation (n = 1311) Resuscitation (n = 212) p value Meconium-stained amniotic fluid 68 (4.5) 55 (4.2) 13 (6.1) 0.277 Birth weight (g) 3050 (2645–3450) 3100 (2750–3500) 2500 (1993–2955) < 0.001 Apgar score (point) 1 min 0–7 79 (5.2) 2 (0.2) 77 (36.3) < 0.001 8–10 1444 (94.8) 1309 (99.8) 135 (63.7) 5 min 0–7 15 (1.0) 1 (0.1) 14 (6.6) < 0.001 8–10 1508 (99.0) 1310 (99.9) 198 (93.4) 10 min 0–7 4 (0.3) 0 (0.0) 4 (1.9) < 0.001 8–10 1519 (99.7) 1311 (100.0) 208 (98.1) NICU 482 (31.6) 290 (22.1) 192 (90.6) < 0.001 Values are median (interquartile range) or n (%). NICU, neonatal intensive care unit. Factors associated with neonatal resuscitation Table 3 shows the results of univariable and multivariable logistic regression analyses. In the multivariate model, independent predictors of neonatal resuscitation included: longer ID time (per minute increase; OR = 1.04, 95% CI 1.01–1.06, p = 0.003), gestational age < 34 weeks (OR = 17.11, 95% CI 10.49–28.17, p < 0.001) and 34–37 weeks (OR = 3.59, 95% CI 2.47–5.26, p < 0.001), ASA physical status III–IV (OR = 1.82, 95% CI 1.13–2.88, p = 0.012), and GA regimen propofol + sevoflurane (OR = 1.94, 95% CI 1.09–3.34, p = 0.021) or other mixed protocols (OR = 8.86, 95% CI 4.55–17.45, p < 0.001) compared with propofol + remifentanil. Table 3 Univariable and multivariable logistic regression analyses for neonatal resuscitation Characteristics Univariable Multivariate OR (95%CI) p value OR (95%CI) p value ID time 1.07 (1.05–1.09) < 0.001 1.04 (1.01–1.06) 0.003 Age ≥ 35 years (vs. <35) 1.31 (0.95–1.79) 0.096 Parity ≥ 1 (vs. 0) 1.82 (1.30–2.59) 0.001 BMI ≥ 28 kg.m − 2 (vs. <28) 1.20 (0.90–1.61) 0.222 Gestational hypertension (vs. no) 2.46 (1.67–3.58) < 0.001 Gestational diabetes mellitus (vs. no) 1.54 (1.03–2.24) 0.029 Autoimmune disease (vs. no) 1.53 (0.81–2.71) 0.168 Anemia (vs. no) 0.97 (0.73–1.30) 0.851 Premature rupture of membranes (vs. no) 1.31 (0.74–2.20) 0.335 Polyhydramnios (vs. no) 1.25 (0.53–2.56) 0.577 Oligohydramnios (vs. no) 0.71 (0.34–1.33) 0.326 Fetal nuchal cord (vs. no) 0.72 (0.47–1.07) 0.118 Previous cesarean delivery (vs. no) 1.61 (1.19–2.20) 0.003 Dexamethasone treatment before delivery (vs. no) 2.11 (1.56–2.85) < 0.001 Non-cephalic (vs. cephalic ) 1.89 (1.25–2.80) 0.002 Labor duration (weeks) < 34 20.71 (13.15-33.00) < 0.001 17.11 (10.49–28.17) < 0.001 34–37 4.06 (2.86–5.81) < 0.001 3.59 (2.47–5.26) < 0.001 ≥ 37 Reference Reference Reasons for GA Placenta previa Reference Coagulation disturbances 0.42 (0.29–0.59) < 0.001 Spine malformation 0.35 (0.16–0.68) 0.004 Other reasons 1.29 (0.88–1.87) 0.186 ASA physical status classification I and II (vs. III and IV) 3.31 (2.38–4.58) < 0.001 1.82 (1.13–2.88) 0.012 GA regimen Propofol + remifentanil + muscle relaxant Reference Reference Propofol + esketamine + muscle relaxant 0.76 (0.40–1.34) 0.369 1.03 (0.52–1.90) 0.936 Propofol + sevoflurane + muscle relaxant 2.01 (1.20–3.24) 0.006 1.94 (1.09–3.34) 0.021 Etomidate + fentanyl + muscle relaxant 1.19 (0.60–2.16) 0.593 1.61 (0.77–3.15) 0.179 Others regimens 16.25 (9.52–28.5) < 0.001 8.86 (4.55–17.45) < 0.001 OR, odds ratio; CI, confidence intervals; ID, incision to delivery; BMI, body mass index; GA, general anesthesia; ASA, American Society of Anesthesiologist Association between ID time and resuscitation probability The restricted cubic spline analysis (Fig. 2 ) demonstrated a continuous, approximately exponential increase in the probability of neonatal resuscitation as ID time prolonged beyond 10 minutes. The 95% confidence interval widened at longer durations, suggesting increasing variability in neonatal outcomes with extended delivery intervals. Discussion Main findings In this multicenter retrospective cohort of 1,523 cesarean deliveries under general anesthesia, prolonged anesthesia ID time was identified as an independent predictor of neonatal resuscitation. Additional risk factors included gestational hypertension, gestational diabetes mellitus, previous cesarean delivery, antenatal dexamethasone exposure, non-cephalic presentation, lower gestational age, higher ASA physical status, and certain anesthetic regimens. A steady, dose–response relationship was observed between ID time and resuscitation probability, indicating that even minor prolongations in delivery may compromise neonatal adaptation. These findings emphasize the importance of minimizing the anesthesia-to-delivery interval to reduce neonatal respiratory depression during cesarean delivery under GA. Optimization of anesthetic technique and intraoperative coordination may mitigate fetal exposure to anesthetic agents, thereby improving perinatal outcomes in high-risk obstetric populations. For patients with contraindications to regional anesthesia, GA remains an important alternative for cesarean delivery [11]. In such cases, the primary concern is the potential depressive effects of anesthetic agents on the neonate [12]. During GA, neonatal compromise is largely attributable to the transplacental passage of anesthetic drugs and uteroplacental hypoperfusion secondary to maternal hypotension, both of which can result in respiratory depression and hypotonia [13–15]. In our study, prolonged ID time during GA was independently associated with an increased likelihood of neonatal resuscitation, confirming the adverse impact of extended fetal exposure to anesthetics on neonatal adaptation after birth. The restricted cubic spline analysis further demonstrated a continuous, nonlinear rise in the probability of resuscitation with increasing ID time, suggesting a dose–response relationship. These findings align with previous reports that longer ID times heighten neonatal exposure to anesthetic agents, leading to respiratory depression, hypoxia, and acidosis [16–18]. For example, Swanson et al. showed that extended ID time during cesarean section under GA independently increased adverse perinatal outcomes, primarily through lower Apgar scores and a higher incidence of respiratory support needs [16]. Collectively, this evidence underscores the importance of expediting delivery following anesthesia induction to reduce neonatal respiratory compromise, even in the context of modern anesthetic and neonatal care. Several clinical and procedural factors have been reported to influence the prolongation of anesthesia ID time during cesarean delivery under general anesthesia. Maternal obesity is a well-recognized contributor, as increased BMI can complicate airway management, slow anesthetic induction, and make surgical exposure more challenging due to excessive adipose tissue and reduced operative visibility [19–21]. Previous cesarean delivery is another important factor, as postoperative adhesions and altered pelvic anatomy can hinder surgical access and delay uterine incision [22,23]. Similarly, technical challenges observed in our study, arising from complex obstetric conditions such as placenta previa or accreta, may also contribute to prolongation of the ID interval. The choice of anesthetic regimen plays a critical role in neonatal outcomes during cesarean delivery under general anesthesia. Etomidate has long been used as an induction agent in obstetric anesthesia because of its rapid onset and minimal cardiovascular depression, providing hemodynamic stability during induction and facilitating timely tracheal intubation, particularly in patients with compromised circulatory function [24–26]. These pharmacologic properties make etomidate-based regimens suitable for emergency cesarean deliveries or for parturients with limited cardiopulmonary reserve. In contrast, combinations involving propofol and sevoflurane have been associated with a higher incidence of neonatal respiratory depression and maternal hypotension, likely due to their greater depressive effects on the cardiovascular and respiratory systems [27,28]. The use of remifentanil, a short-acting opioid with rapid metabolism and minimal accumulation, has been shown to reduce maternal catecholamine response while limiting neonatal exposure because of its low placental transfer and rapid neonatal clearance [29]. Consequently, the propofol + remifentanil regimen may provide a more favorable balance between adequate maternal anesthesia and minimized fetal drug exposure compared with volatile anesthetic techniques. Overall, these findings suggest that anesthetic selection significantly influences the neonatal condition at birth. Regimens that ensure stable maternal hemodynamics and minimize drug accumulation in the fetus, such as etomidate- or remifentanil-based approaches, may help mitigate the risk of neonatal respiratory depression and reduce the need for resuscitation. However, individualized selection of agents remains essential, considering maternal comorbidities, surgical urgency, and institutional experience. Our study also identified several non-anesthetic predictors of neonatal resuscitation, reflecting the multifactorial nature of perinatal compromise. Preterm delivery (< 34 weeks and 34–37 weeks) markedly increased the need for resuscitation, consistent with the vulnerability of premature infants to respiratory failure due to immature pulmonary and neurological function [30]. Gestational hypertension and diabetes were also associated with higher neonatal risk, possibly through impaired placental perfusion and altered fetal oxygenation. Furthermore, higher ASA physical status (III/IV) independently predicted resuscitation, aligning with prior evidence that compromised maternal health status contributes to decreased uteroplacental reserve and fetal hypoxia during operative delivery [31]. The strengths of this study include its multicenter design, large sample size (n = 1,523), and comprehensive assessment of both maternal and perinatal factors. The use of logistic regression and restricted cubic spline analysis provided a detailed understanding of the relationship between continuous ID time and neonatal outcomes. The inclusion of multiple tertiary hospitals in China enhances the external validity and applicability of our findings. However, several limitations must be considered. As a retrospective study, potential selection bias and unmeasured confounders cannot be completely excluded. Institutional differences in anesthesia protocols, surgical urgency, and obstetric practices may have influenced ID time and outcomes, despite standardized perioperative monitoring. Future prospective and comparative studies are warranted to further clarify the causal role of ID time and anesthesia modality on neonatal outcomes and to establish optimal intraoperative management strategies. Conclusion Prolonged ID time under GA was linked to a higher likelihood of neonatal resuscitation intervention. Maternal and procedural characteristics helped identify patients at risk for delay. Optimizing perioperative management and anesthetic selection is crucial to minimizing ID time and improving neonatal safety. Further prospective research is needed to determine optimal ID time thresholds and evaluate targeted interventions for high-risk populations. Abbreviations GA = General Anesthesia; ID = Induction-to-Delivery time; NICU = Neonatal Intensive Care Unit; ASA = American Society of Anesthesiologists Physical Status; BMI = Body Mass Index; RCS = Restricted Cubic Splines. Declarations Acknowledgements The authors would like to thank Professor Xu Qiao, School of Mechanical and Control Engineering, Shandong University, for providing statistical consultation and support. Funding This work was supported by the National Natural Science Foundation of China (Grant No. 82501992), and the Shandong Provincial Natural Science Foundation (Grant No. ZR2025QC1683). Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Conflict of interest The authors declare no competing interests. Statement of ethics The study protocol was approved by the Ethics Committee of Qilu Hospital of Shandong University (KYLL-2023.09-018), with waiver of informed consent due to the retrospective nature. Patient confidentiality and privacy were strictly maintained throughout data collection and analysis. Author contributions CL and LL conceptualized the study. CL, ZZ and RC developed the methodology. CL, ZZ, YG and MY conducted the investigation. CL and ZZ performed the formal analysis. ZZ and YG developed the software. CL and ZZ drafted the original manuscript. LFZ and LL reviewed and edited the manuscript. YG and MY curated the data. LL supervised the study. Consent to Publish declaration: not applicable References Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021;6(6):e005671. Guglielminotti J, Landau R, Li G. 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Plasma catecholamines and neonatal condition after induction of anaesthesia with propofol or thiopentone at caesarean section. Br J Anaesth. 1993;70(3):311-316. Vovk Racman P, Lučovnik M, Stopar Pintarič T. Current Perspectives on Remifentanil-PCA for Labor Analgesia: A Narrative Review. Medicina (Kaunas, Lithuania). 2025;61(9):1550. Wyckoff MH, Wyllie J, Aziz K, et al. Neonatal life support: 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2020;142(16_suppl_1):S185-S221. Gerber C, Bishop DG, Dyer RA, et al. Method of anesthesia and perioperative risk factors, maternal anesthesia complications, and neonatal mortality following cesarean delivery in Africa: a substudy of a 7-day prospective observational cohort study. Anesth Analg. 2024;138(6):1275-1284. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Apr, 2026 Reviews received at journal 16 Apr, 2026 Reviewers agreed at journal 07 Apr, 2026 Reviews received at journal 09 Mar, 2026 Reviewers agreed at journal 24 Feb, 2026 Reviews received at journal 17 Dec, 2025 Reviewers agreed at journal 17 Dec, 2025 Reviewers invited by journal 17 Dec, 2025 Editor invited by journal 15 Dec, 2025 Editor assigned by journal 11 Dec, 2025 Submission checks completed at journal 11 Dec, 2025 First submitted to journal 09 Dec, 2025 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. 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12:31:35","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":125702,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8322063/v1/21119349ad648df45ddaf6c7.html"},{"id":98763286,"identity":"63f6af25-e60c-466c-a9ba-583534c91236","added_by":"auto","created_at":"2025-12-22 10:03:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":755872,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flowchart\u003c/p\u003e\n\u003cp\u003eGA, general anesthesia; ID, incision to delivery.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8322063/v1/e87c104467261077bf3b882c.png"},{"id":98779540,"identity":"6b247917-c1f0-4ea0-b262-b2f13f6f3256","added_by":"auto","created_at":"2025-12-22 12:30:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":169707,"visible":true,"origin":"","legend":"\u003cp\u003eRCS curves of ID time and neonatal resuscitation probability RCS, restricted cubic splines; ID, incision to delivery.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8322063/v1/f36a279bd2a8e5035edaa63a.png"},{"id":98797859,"identity":"4419c390-4d3b-446b-960d-9dd5d6a74a3b","added_by":"auto","created_at":"2025-12-22 13:58:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2234003,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8322063/v1/9d9a986e-aba4-454c-a0f2-8284d10e5c1e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Induction-to-delivery time and neonatal resuscitation after cesarean delivery under general anesthesia: a multicenter retrospective cohort study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith the global rise in cesarean delivery rates, general anesthesia (GA) continues to play a crucial role in obstetric practice, particularly for emergency procedures, contraindications to neuraxial anesthesia, or maternal medical conditions precluding regional techniques [1,2]. Although advancements in anesthetic agents, airway management, and perinatal care have substantially improved safety, neonatal outcomes following cesarean section under GA remain less favorable compared with those under neuraxial anesthesia. Reported adverse outcomes include lower Apgar scores, increased need for resuscitation, and higher neonatal intensive care unit (NICU) admission rates [3,4]. Given that compromised neonatal condition at birth under GA frequently necessitates timely and guideline‑concordant resuscitation, contemporary neonatal life support recommendations highlight the need for rapid assessment and intervention to optimize early postnatal stabilization in this high‑risk population [5,6]. For anesthesiologists, obstetricians, and neonatal teams, understanding modifiable contributors to these outcomes is of direct clinical relevance.\u003c/p\u003e \u003cp\u003eAmong the factors influencing neonatal well-being under GA, the interval between anesthesia induction and fetal delivery\u0026mdash;referred to as the induction-to-delivery (ID) time\u0026mdash;has drawn particular attention as a potentially modifiable determinant. Shorter ID intervals are believed to limit fetal exposure to anesthetic agents and reduce the risk of hypoxia or acidosis [7]. Conversely, prolonged ID time has been associated with depressed neonatal condition, evidenced by lower Apgar scores and increased requirements for resuscitation or NICU care in both preterm and non-elective cesarean deliveries [8,9]. Studies conducted under spinal anesthesia further support this relationship, indicating that extended anesthesia-to-delivery intervals are linked to significant reductions in umbilical arterial pH and higher incidences of neonatal acidosis [10]. However, most existing evidence is derived from regional anesthesia settings, and data specific to GA remain scarce. Considering that GA is still required for patients with contraindications to neuraxial anesthesia or urgent obstetric conditions, understanding its unique risk profile is clinically important.\u003c/p\u003e \u003cp\u003eTherefore, the present study aimed to clarify the association between ID time and neonatal resuscitation during cesarean delivery under GA in a contemporary multicenter cohort. In addition, perioperative and maternal factors contributing to prolonged ID time and adverse neonatal outcomes were analyzed using multivariable modeling to provide evidence for optimizing anesthetic strategies and intraoperative coordination in high-risk obstetric populations.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patient selection\u003c/h2\u003e \u003cp\u003eThis multicenter retrospective cohort study collected data from January 2018 to June 2023 at four tertiary medical centers in China: Qilu Hospital of Shandong University, Shandong Provincial Hospital, First People\u0026rsquo;s Hospital of Lianyungang, and Binzhou Medical University Hospital. Inclusion criteria comprised patients with singleton pregnancies who underwent cesarean delivery under GA for pregnancy termination. Exclusion criteria included incomplete medical records or unclear diagnoses related to the cesarean delivery indication.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBaseline characteristics and anesthesia management\u003c/h3\u003e\n\u003cp\u003eMaternal characteristics recorded included age, parity, body mass index (BMI), gestational age at delivery, gestational hypertension, gestational diabetes mellitus, autoimmune disease, anemia (hemoglobin\u0026thinsp;\u0026lt;\u0026thinsp;110 g/L), premature rupture of membranes, polyhydramnios, oligohydramnios, fetal nuchal cord, previous cesarean delivery, and antenatal dexamethasone treatment. Fetal factors included presentation (cephalic vs non-cephalic), and indications for GA (placenta previa, coagulation disturbances, spine malformation, or other causes). Preoperative physical status was classified according to the American Society of Anesthesiologists (ASA).\u003c/p\u003e \u003cp\u003eGA was induced intravenously based on institutional protocols using one of the following regimens: propofol\u0026thinsp;+\u0026thinsp;remifentanil, propofol\u0026thinsp;+\u0026thinsp;esketamine, propofol\u0026thinsp;+\u0026thinsp;sevoflurane, or etomidate\u0026thinsp;+\u0026thinsp;fentanyl, each combined with a neuromuscular blocking agent to facilitate tracheal intubation. Anesthetic drug selection, dosage, and maintenance were determined by attending anesthesiologists according to maternal condition and surgical requirements. Standard intraoperative monitoring and obstetric anesthesia management were uniformly applied.\u003c/p\u003e \u003cp\u003eNeonatal variables collected included anesthesia ID time, meconium-stained amniotic fluid, birth weight, Apgar scores at 1, 5, and 10 minutes, need for resuscitation (defined as tracheal intubation or positive pressure ventilation via facemask), and NICU admission.\u003c/p\u003e\n\u003ch3\u003eEndpoints\u003c/h3\u003e\n\u003cp\u003eThe primary endpoint was to identify clinical factors associated with neonatal resuscitation following GA cesarean delivery. Neonatal resuscitation was initiated when the newborn exhibited no spontaneous respiration, heart rate\u0026thinsp;\u0026lt;\u0026thinsp;100 bpm, 1-minute Apgar score\u0026thinsp;\u0026lt;\u0026thinsp;7, decreased tone, or respiratory depression, particularly in cases of maternal anesthetic exposure or suspected uteroplacental hypoperfusion [9,10].\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eBaseline characteristics were described using frequencies (%) or medians with interquartile ranges. Categorical variables were compared using the chi-square test, and continuous variables using the Wilcoxon rank-sum test. Univariable logistic regression was first performed to identify potential factors associated with neonatal resuscitation. Variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.10 were entered into a multivariate logistic regression model using backward stepwise elimination. Results were reported as odds ratio (OR) with 95% confidence intervals (CIs). The relationship between ID time and the probability of neonatal resuscitation was visualized using restricted cubic spline (RCS) models to capture potential nonlinear associations.\u003c/p\u003e \u003cp\u003eAll statistical analyses were conducted using R software (version 4.5.1; R Foundation for Statistical Computing, Vienna, Austria). Two-sided p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study flowchart is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 1,523 patients who underwent cesarean delivery under GA were included in the analysis. Based on neonatal outcomes, 1,311 neonates (86.1%) did not require resuscitation, while 212 neonates (13.9%) underwent resuscitation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eComparison of maternal and perinatal characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes baseline maternal and obstetric characteristics. Compared with the non-resuscitation group, neonates who required resuscitation were more frequently born to mothers with: parity\u0026thinsp;\u0026ge;\u0026thinsp;1 (77.8% vs 65.8%, p\u0026thinsp;=\u0026thinsp;0.001), gestational hypertension (20.8% vs 9.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), gestational diabetes mellitus (17.9% vs 12.4%, p\u0026thinsp;=\u0026thinsp;0.037), previous cesarean delivery (67.9% vs 56.8%, p\u0026thinsp;=\u0026thinsp;0.003), and antenatal dexamethasone exposure (41.5% vs 25.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The distribution of gestational age differed significantly between groups, with higher proportions of preterm births at \u0026lt;\u0026thinsp;34 weeks (30.2% vs 3.8%) and 34\u0026ndash;37 weeks (43.9% vs 28.3%) in the resuscitation group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In addition, the non-cephalic presentation and ASA physical status III\u0026ndash;IV were more frequent among resuscitated neonates (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for both).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of pre-delivery characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1523)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo resuscitation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1311)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResuscitation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;212)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eID time (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (7\u0026ndash;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (8\u0026ndash;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (year)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1127 (74.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e980 (74.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e147 (69.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e396 (26.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e331 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65 (30.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e495 (32.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e448 (34.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1028 (67.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e863 (65.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e165 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg m\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e749 (49.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e653 (49.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96 (45.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e774 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e658 (50.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e116 (54.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eObstetric complications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational diabetes mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e201 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e163 (12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutoimmune disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e785 (51.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e677 (51.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108 (50.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.909\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePremature rupture of membranes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolyhydramnios\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOligohydramnios\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFetal nuchal cord\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e274 (18.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e244 (18.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious cesarean delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e889 (58.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e745 (56.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e144 (67.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDexamethasone treatment before delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e418 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e330 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFetal presentation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCephalic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1359 (89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1183 (90.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e176 (83.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-cephalic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128 (9.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLabor duration (weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e34\u0026ndash;37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e464 (30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e371 (28.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93 (43.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e945 (62.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e890 (67.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReasons for GA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlacenta previa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e509 (33.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e416 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93 (43.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoagulation disturbances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e644 (42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e589 (44.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpine malformation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e115 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e246 (16.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e191 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA physical status classification\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI and II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1279 (84.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1138 (86.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e141 (66.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII and IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e244 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e173 (13.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71 (33.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGA regimen\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePropofol\u0026thinsp;+\u0026thinsp;remifentanil\u0026thinsp;+\u0026thinsp;muscle relaxant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1095 (71.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e975 (74.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e120 (56.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePropofol\u0026thinsp;+\u0026thinsp;esketamine\u0026thinsp;+\u0026thinsp;muscle relaxant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePropofol\u0026thinsp;+\u0026thinsp;sevoflurane\u0026thinsp;+\u0026thinsp;muscle relaxant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116 (7.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtomidate\u0026thinsp;+\u0026thinsp;fentanyl\u0026thinsp;+\u0026thinsp;muscle relaxant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (6.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eValues are median (interquartile range) or n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eBMI, body mass index; ASA, American Society of Anesthesiologists; GA, general anesthesia; ID, incision to delivery.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eComparison of neonatal outcomes\u003c/h3\u003e\n\u003cp\u003ePerinatal and neonatal outcomes are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Compared with neonates not requiring resuscitation, those in the resuscitation group had: lower median birth weights (2500 g [1993\u0026ndash;2955] vs 3100 g [2750\u0026ndash;3500], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); markedly lower 1-minute Apgar scores (Apgar 0\u0026ndash;7: 36.3% vs 0.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); and higher NICU admission rates (90.6% vs 22.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of perinatal neonatal outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1523)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo resuscitation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1311)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResuscitation\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;212)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMeconium-stained amniotic fluid\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth weight (g)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3050 (2645\u0026ndash;3450)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3100 (2750\u0026ndash;3500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2500 (1993\u0026ndash;2955)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eApgar score (point)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77 (36.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1444 (94.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1309 (99.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e135 (63.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14 (6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1508 (99.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1310 (99.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e198 (93.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1519 (99.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1311 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e208 (98.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNICU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e482 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e290 (22.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e192 (90.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eValues are median (interquartile range) or n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNICU, neonatal intensive care unit.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eFactors associated with neonatal resuscitation\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the results of univariable and multivariable logistic regression analyses. In the multivariate model, independent predictors of neonatal resuscitation included: longer ID time (per minute increase; OR\u0026thinsp;=\u0026thinsp;1.04, 95% CI 1.01\u0026ndash;1.06, p\u0026thinsp;=\u0026thinsp;0.003), gestational age\u0026thinsp;\u0026lt;\u0026thinsp;34 weeks (OR\u0026thinsp;=\u0026thinsp;17.11, 95% CI 10.49\u0026ndash;28.17, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 34\u0026ndash;37 weeks (OR\u0026thinsp;=\u0026thinsp;3.59, 95% CI 2.47\u0026ndash;5.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ASA physical status III\u0026ndash;IV (OR\u0026thinsp;=\u0026thinsp;1.82, 95% CI 1.13\u0026ndash;2.88, p\u0026thinsp;=\u0026thinsp;0.012), and GA regimen propofol\u0026thinsp;+\u0026thinsp;sevoflurane (OR\u0026thinsp;=\u0026thinsp;1.94, 95% CI 1.09\u0026ndash;3.34, p\u0026thinsp;=\u0026thinsp;0.021) or other mixed protocols (OR\u0026thinsp;=\u0026thinsp;8.86, 95% CI 4.55\u0026ndash;17.45, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared with propofol\u0026thinsp;+\u0026thinsp;remifentanil.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariable and multivariable logistic regression analyses for neonatal resuscitation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMultivariate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eID time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.07 (1.05\u0026ndash;1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.04 (1.01\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;35 years (vs. \u0026lt;35)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.31 (0.95\u0026ndash;1.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u0026thinsp;\u0026ge;\u0026thinsp;1 (vs. 0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.82 (1.30\u0026ndash;2.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u0026thinsp;\u0026ge;\u0026thinsp;28 kg.m\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026minus;\u0026thinsp;2\u003c/b\u003e\u003c/sup\u003e \u003cb\u003e(vs. \u0026lt;28)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.20 (0.90\u0026ndash;1.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational hypertension (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.46 (1.67\u0026ndash;3.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational diabetes mellitus (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.54 (1.03\u0026ndash;2.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAutoimmune disease (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.53 (0.81\u0026ndash;2.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnemia (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.97 (0.73\u0026ndash;1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePremature rupture of membranes (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.31 (0.74\u0026ndash;2.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePolyhydramnios (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.25 (0.53\u0026ndash;2.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.577\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOligohydramnios (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.71 (0.34\u0026ndash;1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFetal nuchal cord (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.72 (0.47\u0026ndash;1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious cesarean delivery (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.61 (1.19\u0026ndash;2.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDexamethasone treatment before delivery (vs. no)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.11 (1.56\u0026ndash;2.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNon-cephalic (vs. cephalic )\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.89 (1.25\u0026ndash;2.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLabor duration (weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.71 (13.15-33.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.11 (10.49\u0026ndash;28.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e34\u0026ndash;37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.06 (2.86\u0026ndash;5.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.59 (2.47\u0026ndash;5.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReasons for GA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlacenta previa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoagulation disturbances\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.42 (0.29\u0026ndash;0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpine malformation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.35 (0.16\u0026ndash;0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther reasons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.29 (0.88\u0026ndash;1.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA physical status classification I and II (vs. III and IV)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.31 (2.38\u0026ndash;4.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.82 (1.13\u0026ndash;2.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGA regimen\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePropofol\u0026thinsp;+\u0026thinsp;remifentanil\u0026thinsp;+\u0026thinsp;muscle relaxant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePropofol\u0026thinsp;+\u0026thinsp;esketamine\u0026thinsp;+\u0026thinsp;muscle relaxant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.76 (0.40\u0026ndash;1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.369\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.03 (0.52\u0026ndash;1.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.936\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePropofol\u0026thinsp;+\u0026thinsp;sevoflurane\u0026thinsp;+\u0026thinsp;muscle relaxant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.01 (1.20\u0026ndash;3.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.94 (1.09\u0026ndash;3.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtomidate\u0026thinsp;+\u0026thinsp;fentanyl\u0026thinsp;+\u0026thinsp;muscle relaxant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.19 (0.60\u0026ndash;2.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.61 (0.77\u0026ndash;3.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers regimens\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.25 (9.52\u0026ndash;28.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.86 (4.55\u0026ndash;17.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eOR, odds ratio; CI, confidence intervals; ID, incision to delivery; BMI, body mass index; GA, general anesthesia; ASA, American Society of Anesthesiologist\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAssociation between ID time and resuscitation probability\u003c/h2\u003e \u003cp\u003eThe restricted cubic spline analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) demonstrated a continuous, approximately exponential increase in the probability of neonatal resuscitation as ID time prolonged beyond 10 minutes. The 95% confidence interval widened at longer durations, suggesting increasing variability in neonatal outcomes with extended delivery intervals.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMain findings\u003c/h2\u003e \u003cp\u003eIn this multicenter retrospective cohort of 1,523 cesarean deliveries under general anesthesia, prolonged anesthesia ID time was identified as an independent predictor of neonatal resuscitation. Additional risk factors included gestational hypertension, gestational diabetes mellitus, previous cesarean delivery, antenatal dexamethasone exposure, non-cephalic presentation, lower gestational age, higher ASA physical status, and certain anesthetic regimens. A steady, dose\u0026ndash;response relationship was observed between ID time and resuscitation probability, indicating that even minor prolongations in delivery may compromise neonatal adaptation. These findings emphasize the importance of minimizing the anesthesia-to-delivery interval to reduce neonatal respiratory depression during cesarean delivery under GA. Optimization of anesthetic technique and intraoperative coordination may mitigate fetal exposure to anesthetic agents, thereby improving perinatal outcomes in high-risk obstetric populations.\u003c/p\u003e \u003cp\u003eFor patients with contraindications to regional anesthesia, GA remains an important alternative for cesarean delivery [11]. In such cases, the primary concern is the potential depressive effects of anesthetic agents on the neonate [12]. During GA, neonatal compromise is largely attributable to the transplacental passage of anesthetic drugs and uteroplacental hypoperfusion secondary to maternal hypotension, both of which can result in respiratory depression and hypotonia [13\u0026ndash;15]. In our study, prolonged ID time during GA was independently associated with an increased likelihood of neonatal resuscitation, confirming the adverse impact of extended fetal exposure to anesthetics on neonatal adaptation after birth. The restricted cubic spline analysis further demonstrated a continuous, nonlinear rise in the probability of resuscitation with increasing ID time, suggesting a dose\u0026ndash;response relationship. These findings align with previous reports that longer ID times heighten neonatal exposure to anesthetic agents, leading to respiratory depression, hypoxia, and acidosis [16\u0026ndash;18]. For example, Swanson et al. showed that extended ID time during cesarean section under GA independently increased adverse perinatal outcomes, primarily through lower Apgar scores and a higher incidence of respiratory support needs [16]. Collectively, this evidence underscores the importance of expediting delivery following anesthesia induction to reduce neonatal respiratory compromise, even in the context of modern anesthetic and neonatal care.\u003c/p\u003e \u003cp\u003eSeveral clinical and procedural factors have been reported to influence the prolongation of anesthesia ID time during cesarean delivery under general anesthesia. Maternal obesity is a well-recognized contributor, as increased BMI can complicate airway management, slow anesthetic induction, and make surgical exposure more challenging due to excessive adipose tissue and reduced operative visibility [19\u0026ndash;21]. Previous cesarean delivery is another important factor, as postoperative adhesions and altered pelvic anatomy can hinder surgical access and delay uterine incision [22,23]. Similarly, technical challenges observed in our study, arising from complex obstetric conditions such as placenta previa or accreta, may also contribute to prolongation of the ID interval.\u003c/p\u003e \u003cp\u003eThe choice of anesthetic regimen plays a critical role in neonatal outcomes during cesarean delivery under general anesthesia. Etomidate has long been used as an induction agent in obstetric anesthesia because of its rapid onset and minimal cardiovascular depression, providing hemodynamic stability during induction and facilitating timely tracheal intubation, particularly in patients with compromised circulatory function [24\u0026ndash;26]. These pharmacologic properties make etomidate-based regimens suitable for emergency cesarean deliveries or for parturients with limited cardiopulmonary reserve. In contrast, combinations involving propofol and sevoflurane have been associated with a higher incidence of neonatal respiratory depression and maternal hypotension, likely due to their greater depressive effects on the cardiovascular and respiratory systems [27,28]. The use of remifentanil, a short-acting opioid with rapid metabolism and minimal accumulation, has been shown to reduce maternal catecholamine response while limiting neonatal exposure because of its low placental transfer and rapid neonatal clearance [29]. Consequently, the propofol\u0026thinsp;+\u0026thinsp;remifentanil regimen may provide a more favorable balance between adequate maternal anesthesia and minimized fetal drug exposure compared with volatile anesthetic techniques. Overall, these findings suggest that anesthetic selection significantly influences the neonatal condition at birth. Regimens that ensure stable maternal hemodynamics and minimize drug accumulation in the fetus, such as etomidate- or remifentanil-based approaches, may help mitigate the risk of neonatal respiratory depression and reduce the need for resuscitation. However, individualized selection of agents remains essential, considering maternal comorbidities, surgical urgency, and institutional experience.\u003c/p\u003e \u003cp\u003eOur study also identified several non-anesthetic predictors of neonatal resuscitation, reflecting the multifactorial nature of perinatal compromise. Preterm delivery (\u0026lt;\u0026thinsp;34 weeks and 34\u0026ndash;37 weeks) markedly increased the need for resuscitation, consistent with the vulnerability of premature infants to respiratory failure due to immature pulmonary and neurological function [30]. Gestational hypertension and diabetes were also associated with higher neonatal risk, possibly through impaired placental perfusion and altered fetal oxygenation. Furthermore, higher ASA physical status (III/IV) independently predicted resuscitation, aligning with prior evidence that compromised maternal health status contributes to decreased uteroplacental reserve and fetal hypoxia during operative delivery [31].\u003c/p\u003e \u003cp\u003eThe strengths of this study include its multicenter design, large sample size (n\u0026thinsp;=\u0026thinsp;1,523), and comprehensive assessment of both maternal and perinatal factors. The use of logistic regression and restricted cubic spline analysis provided a detailed understanding of the relationship between continuous ID time and neonatal outcomes. The inclusion of multiple tertiary hospitals in China enhances the external validity and applicability of our findings. However, several limitations must be considered. As a retrospective study, potential selection bias and unmeasured confounders cannot be completely excluded. Institutional differences in anesthesia protocols, surgical urgency, and obstetric practices may have influenced ID time and outcomes, despite standardized perioperative monitoring. Future prospective and comparative studies are warranted to further clarify the causal role of ID time and anesthesia modality on neonatal outcomes and to establish optimal intraoperative management strategies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eProlonged ID time under GA was linked to a higher likelihood of neonatal resuscitation intervention. Maternal and procedural characteristics helped identify patients at risk for delay. Optimizing perioperative management and anesthetic selection is crucial to minimizing ID time and improving neonatal safety. Further prospective research is needed to determine optimal ID time thresholds and evaluate targeted interventions for high-risk populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGA = General Anesthesia;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eID = Induction-to-Delivery time;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNICU = Neonatal Intensive Care Unit;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eASA = American Society of Anesthesiologists Physical Status;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBMI = Body Mass Index;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRCS = Restricted Cubic Splines.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Professor Xu Qiao, School of Mechanical and Control Engineering, Shandong University, for providing statistical consultation and support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Natural Science Foundation of China (Grant No. 82501992), and the Shandong Provincial Natural Science Foundation (Grant No. ZR2025QC1683).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of Qilu Hospital of Shandong University (KYLL-2023.09-018), with waiver of informed consent due to the retrospective nature. Patient confidentiality and privacy were strictly maintained throughout data collection and analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCL and LL conceptualized the study. CL, ZZ and RC developed the methodology. CL, ZZ, YG and MY conducted the investigation. CL and ZZ performed the formal analysis. ZZ and YG developed the software. CL and ZZ drafted the original manuscript. LFZ and LL reviewed and edited the manuscript. YG and MY curated the data. LL supervised the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBetran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021;6(6):e005671.\u003c/li\u003e\n\u003cli\u003eGuglielminotti J, Landau R, Li G. Adverse events and factors associated with potentially avoidable use of general anesthesia in cesarean deliveries. Anesthesiology. 2019;130(6):912-922.\u003c/li\u003e\n\u003cli\u003eChen YC, Liang FW, Tan PH, Ho CH, Chang YJ, Hung KC, et al. Association between general anesthesia for cesarean delivery and subsequent developmental disorders in children: a nationwide retrospective cohort study. BMC Med. 2025;23(1):119.\u003c/li\u003e\n\u003cli\u003eCocchi E, Pini R, Gallipoli A, Stella M, Antonazzo P, Marchetti F, et al. Impact of general vs neuraxial anesthesia on neonatal outcomes in non-elective cesarean sections. Front Pediatr. 2025;13:1518456.\u003c/li\u003e\n\u003cli\u003eGreif R, Bray JE, Dj\u0026auml;rv T, et al. 2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2024;150(24):e580-e687.\u003c/li\u003e\n\u003cli\u003eKariuki E, Sutton C, Leone TA. Neonatal resuscitation: current evidence and guidelines. BJA Educ. 2021;21(12):479-485.\u003c/li\u003e\n\u003cli\u003eWatson SE, Richardson AL, Lucas DN. Neuraxial and general anaesthesia for caesarean section. Best Pract Res Clin Anaesthesiol. 2022;36(1):53-68.\u003c/li\u003e\n\u003cli\u003eWang L, Liu C, Wang X, Zhu S, Zhang L, Wang B, et al. The impact of general anesthesia on the outcomes of preterm infants with gestational age less than 32 weeks delivered via cesarean section. Front Pharmacol. 2024;15:1360691.\u003c/li\u003e\n\u003cli\u003eCocchi E, Pini R, Gallipoli A, Stella M, Antonazzo P, Marchetti F, et al. Impact of general vs neuraxial anesthesia on neonatal outcomes in non-elective cesarean sections. Front Pediatr. 2025;13:1518456.\u003c/li\u003e\n\u003cli\u003eHassanin AS, El-Shahawy HF, Hussain SH, Bahaa Eldin AM, Elhawary MM, Elbakery M, et al. Impact of interval between induction of spinal anesthesia to delivery on umbilical arterial cord ph of neonates delivered by elective cesarean section. BMC Pregnancy Childbirth. 2022;22(1):216.\u003c/li\u003e\n\u003cli\u003eBrogly N, Valbuena G\u0026oacute;mez I, Afshari A, Ekelund K, Kranke P, Weiniger CF, et al. ESAIC focused guidelines for the management of the failing epidural during labour epidural analgesia. Eur J Anaesthesiol. 2025;42(2):96-112.\u003c/li\u003e\n\u003cli\u003eReynolds F, Seed PT. Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia. 2005;60(7):636-653.\u003c/li\u003e\n\u003cli\u003eBrogly N, Valbuena G\u0026oacute;mez I, Afshari A, Ekelund K, Kranke P, Weiniger CF, et al. ESAIC focused guidelines for the management of the failing epidural during labour epidural analgesia. Eur J Anaesthesiol. 2025;42(2):96-112.\u003c/li\u003e\n\u003cli\u003eReynolds F, Seed PT. Anaesthesia for Caesarean section and neonatal acid-base status: a meta-analysis. Anaesthesia. 2005;60(7):636-653.\u003c/li\u003e\n\u003cli\u003eGwanzura C, Gavi S, Mangiza M, Moyo FV, Lohman MC, Nhemachena T, et al. Effect of anesthesia administration method on apgar scores of infants born to women undergoing elective cesarean section. BMC Anesthesiol. 2023;23(1):142.\u003c/li\u003e\n\u003cli\u003eSwanson K, Liang L, Grobman WA, Higgins N, Roy A, Son M. Duration of exposure to general endotracheal anesthesia during cesarean deliveries at term and perinatal complications. Am J Perinatol. 2022;39(3):232-237.\u003c/li\u003e\n\u003cli\u003eRing L, Landau R, Delgado C. The current role of general anesthesia for cesarean delivery. Curr Anesthesiol Rep. 2021;11(1):18-27.\u003c/li\u003e\n\u003cli\u003eDatta S, Ostheimer GW, Weiss JB, Brown WU Jr, Alper MH. Neonatal effect of prolonged anesthetic induction for cesarean section. Obstet Gynecol. 1981;58(3):331-335.\u003c/li\u003e\n\u003cli\u003eJuvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97(2):595-600.\u003c/li\u003e\n\u003cli\u003eShailaja S, Nichelle SM, Shetty AK, Hegde BR. Comparing ease of intubation in obese and lean patients using intubation difficulty scale. Anesth Essays Res. 2014;8(2):168-174.\u003c/li\u003e\n\u003cli\u003eVisconti F, Quaresima P, Rania E, Palumbo AR, Micieli M, Zullo F, et al. Difficult caesarean section: a literature review. Eur J Obstet Gynecol Reprod Biol. 2020;246:72-78.\u003c/li\u003e\n\u003cli\u003eSilver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226-1232.\u003c/li\u003e\n\u003cli\u003eMarshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet Gynecol. 2011;205(3):262.e1-8.\u003c/li\u003e\n\u003cli\u003eLiu H, Miao JK, Cai M, Gan L, Zhao HQ, Lei XF, et al. Anesthetic drug concentrations and placental transfer rate in fetus between term and preterm infants, twins, and singletons. Front Pharmacol. 2023;14:1213734.\u003c/li\u003e\n\u003cli\u003eReich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, et al. Predictors of hypotension after induction of general anesthesia. Anesth Analg. 2005;101(3):622-628.\u003c/li\u003e\n\u003cli\u003eForman SA. Clinical and molecular pharmacology of etomidate. Anesthesiology. 2011;114(3):695-707.\u003c/li\u003e\n\u003cli\u003eEbert TJ. Cardiovascular and autonomic effects of sevoflurane. Acta Anaesthesiol Belg. 1996;47(1):15-21.\u003c/li\u003e\n\u003cli\u003eGin T, O\u0026apos;Meara ME, Kan AF, Leung RK, Tan P, Yau G. Plasma catecholamines and neonatal condition after induction of anaesthesia with propofol or thiopentone at caesarean section. Br J Anaesth. 1993;70(3):311-316.\u003c/li\u003e\n\u003cli\u003eVovk Racman P, Lučovnik M, Stopar Pintarič T. Current Perspectives on Remifentanil-PCA for Labor Analgesia: A Narrative Review. Medicina (Kaunas, Lithuania). 2025;61(9):1550.\u003c/li\u003e\n\u003cli\u003eWyckoff MH, Wyllie J, Aziz K, et al. Neonatal life support: 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2020;142(16_suppl_1):S185-S221.\u003c/li\u003e\n\u003cli\u003eGerber C, Bishop DG, Dyer RA, et al. Method of anesthesia and perioperative risk factors, maternal anesthesia complications, and neonatal mortality following cesarean delivery in Africa: a substudy of a 7-day prospective observational cohort study. Anesth Analg. 2024;138(6):1275-1284.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"general anesthesia, cesarean delivery, induction-to-delivery time, neonatal resuscitation, risk factors","lastPublishedDoi":"10.21203/rs.3.rs-8322063/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8322063/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeneral anesthesia (GA) remains essential for cesarean delivery in emergencies or when neuraxial anesthesia is contraindicated, but it is associated with less favorable neonatal outcomes. Among potential contributors, the induction-to-delivery (ID) time—defined as the interval from the administration of general anesthetic agents to fetal expulsion—has emerged as a key and potentially modifiable factor. This study aimed to assess the relationship between ID time and the need for neonatal resuscitation during GA cesarean delivery, and to identify perioperative and maternal factors associated with increased resuscitation risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA multicenter retrospective study was conducted among women with singleton pregnancies who underwent cesarean delivery under GA for pregnancy termination. Baseline maternal, anesthetic, and neonatal variables were collected. Categorical variables were analyzed using the Chi-square test, and continuous variables using the Wilcoxon rank-sum test. Univariable and multivariable logistic regression models were applied to identify independent risk factors for neonatal resuscitation, and a restricted cubic spline (RCS) model was used to evaluate the relationship between ID time and the probability of resuscitation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 1,523 cases were included; 212 neonates (13.9%) required resuscitation. Prolonged ID time was independently associated with an increased likelihood of neonatal resuscitation (OR = 1.04 per minute; 95% CI 1.01–1.06, p = 0.003). Additional predictors included gestational age \u0026lt; 34 weeks (OR = 17.11, 95% CI 10.49–28.17), gestational age 34–37 weeks (OR = 3.59, 95% CI 2.47–5.26), American Society of Anesthesiologists Physical Status III–IV (OR = 1.82, 95% CI 1.13–2.88), and anesthetic regimens involving propofol + sevoflurane (OR = 1.94, 95% CI 1.09–3.34) or mixed agents (OR = 8.86, 95% CI 4.55–17.45) compared with propofol + remifentanil. RCS analysis showed a nonlinear positive association between ID time and the probability of neonatal resuscitation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProlonged ID time under GA constitutes a modifiable risk factor for neonatal resuscitation. Shortening ID time may help improve neonatal outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003enot applicable.\u003c/p\u003e","manuscriptTitle":"Induction-to-delivery time and neonatal resuscitation after cesarean delivery under general anesthesia: a multicenter retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 10:03:17","doi":"10.21203/rs.3.rs-8322063/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-27T18:42:17+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-17T03:40:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204048167600645172945308053944692766280","date":"2026-04-07T19:40:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-09T16:28:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36285767311434887400728026452186713664","date":"2026-02-24T11:46:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-17T23:52:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177347860720028791787191493614770537634","date":"2025-12-17T22:22:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-17T08:44:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-15T16:19:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-11T14:22:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-11T14:16:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2025-12-10T01:55:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"db55fc7f-57ef-4cc9-b8dc-ec3afd132ea2","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T03:38:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 10:03:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8322063","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8322063","identity":"rs-8322063","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}