{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,23]],"date-time":"2026-08-23T16:55:26Z","timestamp":1787504126380,"version":"build-2736575974"},"reference-count":63,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2023,10,3]],"date-time":"2023-10-03T00:00:00Z","timestamp":1696291200000},"content-version":"vor","delay-in-days":2,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Ultrasound in Obstet &amp;amp; Gyne"],"published-print":{"date-parts":[[2023,10]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To review the evidence on the effect of mode of delivery on perinatal outcome of fetuses born before 32\u2009weeks' gestation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), the\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"http:\/\/ClinicalTrials.gov\">ClinicalTrials.gov<\/jats:ext-link>\n                      registry and gray literature sources were searched, starting from the year 2000 to reflect contemporary practice in perinatal care. Non\u2010randomized or randomized studies that included singleton fetuses without chromosomal abnormality or major congenital defect delivered vaginally or via Cesarean section were eligible for inclusion in the analysis. Primary outcomes were neonatal death, defined as death in the first 28\u2009days of age, and survival to discharge. Secondary outcomes were other adverse perinatal events. The ROBINS\u2010I tool was used to assess the risk of bias. The overall quality of evidence for the outcomes was assessed according to GRADE. Summary odds ratios (ORs) with 95%\u2009CIs were calculated, and random\u2010effects models were used for data synthesis. Subgroup analysis was performed for delivery before 28\u2009weeks, delivery between 28 and 32\u2009weeks and according to fetal presentation at delivery.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 27 retrospective studies (22\u2009887 neonates) were included in the systematic review and meta\u2010analysis, all of which reported on singleton pregnancies. Among cases born before 28\u2009weeks, vaginal delivery significantly increased the risk of neonatal death of fetuses with any type of presentation (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20091496) (OR 1.87 (95%\u2009CI, 1.05\u20133.35);\n                      <jats:italic>I<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      \u2009=\u200965%, very low quality of evidence) and of fetuses with breech presentation (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009733) (OR 3.55 (95%\u2009CI, 2.42\u20135.21);\n                      <jats:italic>I<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      \u2009=\u200921%, moderate quality of evidence). The odds of survival to discharge were significantly decreased among fetuses with breech presentation delivered before 28\u2009weeks (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009646) (OR 0.36 (95%\u2009CI, 0.24\u20130.54);\n                      <jats:italic>I<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      \u2009=\u200921%, low quality of evidence). Among breech fetuses born between 28 and 32\u2009weeks, vaginal delivery increased the odds of perinatal death (intrapartum and neonatal) (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20091581) (OR 3.06 (95%\u2009CI, 1.47\u20136.35);\n                      <jats:italic>I<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      \u2009=\u20090%, high quality of evidence). In non\u2010cephalic fetuses born between 24 and 32\u2009weeks, vaginal delivery decreased the odds of survival to discharge (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20091030) (OR 0.28 (95%\u2009CI, 0.19\u20130.40);\n                      <jats:italic>I<\/jats:italic>\n                      <jats:sup>2<\/jats:sup>\n                      \u2009=\u20090%, moderate quality of evidence). No significant effect on mortality of mode of delivery was observed in cephalic fetuses at any gestational age.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      This systematic review and meta\u2010analysis suggests that vaginal delivery in severe preterm birth is associated with an increased risk of neonatal and perinatal death in breech fetuses, while no significant association was observed for cephalic fetuses. \u00a9 2023 The Authors.\n                      <jats:italic>Ultrasound in Obstetrics &amp; Gynecology<\/jats:italic>\n                      published by John Wiley &amp; Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.\n                    <\/jats:p>\n                  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