Respiratory distress after planned births compared to expectant management - Target trial emulation.

Summary

In a target trial emulation of 575,817 Swedish singleton births, induction of labor carried no excess neonatal respiratory distress risk from 38 weeks onward, whereas elective cesarean reached risk neutrality only from 40 weeks. Earlier elective cesarean was associated with markedly higher absolute and relative risks and increased odds of Apgar <7.

Key Findings

• No excess respiratory distress risk for induction from 38 weeks and for elective cesarean from 40 weeks versus expectant management.
• At 37 weeks, absolute respiratory distress risk was 12.4% for elective cesarean (aRR 5.7, 95% CI 4.8–6.5) and 4.0% for induction (aRR 1.7, 95% CI 1.5–2.0).
• Elective cesarean at 39 weeks had 3.2% absolute risk (aRR 1.6, 95% CI 1.3–1.8), and elective cesarean <38 weeks increased risk of Apgar <7.

Clinical Implications

Prefer induction from ≥38 weeks and elective cesarean from ≥40 weeks when medically reasonable to reduce neonatal respiratory distress and low Apgar risk. Avoid early elective cesarean (<38 weeks) without compelling indications.

Limitations

• Observational registry study susceptible to residual confounding and indication bias
• Generalizability may be limited outside Sweden; exclusions may omit higher-risk populations

Future Directions

Replicate in other health systems; integrate maternal outcomes and stratify by indications; assess impacts of policy changes on respiratory morbidity.