Professional Documents
Culture Documents
PhD,
MB ChB, MD
1169
Year (Years
Assessed)
First Author
2010 (19672001)
Moster25
Norway
Not defined
Term
2010 (19902005)
2008 (19821990)
Kulak26
Nielsen27
Poland
Denmark
Not defined
Emergency
Term
Not defined
Stelmach28
Estonia
Emergency
Not defined
2006 (19902000)
2004 (19841993)
Gurbuz29
Greenwood30
Turkey
United
Kingdom
Elective
Not defined
Elective
Not defined
Not defined
Term
Elective
Preterm, 32 wk of
gestation or less
Preterm, 3336 wk
of gestation
Preterm, less than
32 wk of gestation
Preterm, less than
32 wk of gestation
2428 wk of
gestation
Preterm, 2433 wk
of gestation
Country
Cesarean
Type
Elective
1995 (19841990)
Murphy31
United
Kingdom
Emergency
Elective
Gestational
Age
Presentation
Study Design
1985 (19771982)
Kitchen32
Australia
Not defined
1998 (19781989)
OShea33
United States
Not defined
1999 (19791986)
Krebs34
Denmark
1985 (19711977)
Svenningsen35 Sweden
Not defined
Term
Churchill36
Not defined
2011 (19902005)
OCallaghan20 Australia
United States
Term
Emergency
Elective
Not defined
CP, cerebral palsy; OR, odds ratio; CI, confidence interval; GA, gestational age.
SOURCES
The search strategy considered only full articles published in English. Articles published until December
1170
STUDY SELECTION
Relevant references cited within these articles were
also selected. For inclusion, articles needed to report
cerebral palsy as an endpoint with cesarean delivery
as a risk factor and provide sufficient details for
inclusion in a meta-analysis. The review did not
include cases in which a confirmed neurologic diagnosis of cerebral palsy was absent. Articles undergoing full-text review were considered for inclusion by
both authors and discrepancies were resolved by
discussion. Data were extracted from articles using
Case Definition
CP diagnosis in
benefits record
CP diagnosed at
age 25 y
Spastic CP
CP diagnosis
CP diagnosis at
age 2 y
CP diagnosis at
age 5 y
On CP register,
age 35 y
Control Definition
Singletons born
19672001
Non-CP
Non-CP
From birth register,
matched
OR
120,793/1,680,503
2.17
50/280
1.6
1.042.47
51/217
8/268
1.7
4.3
1.092.65
1.7610.5
1.135.68
0.973.03
95% CI
1.92.5
17/153
26/101
Non-CP
13/268
46/308
2.54
1.7
10/126
Non-CP
12/290
2.6
1.16.3
12/73
11/36
12/59
Non-CP
Non-CP
Selected from population
birth register
114/286
15/70
19/234
0.3
2
2.7
0.20.7
0.85.3
1.26.1
98/234
26/144
57/80 (not GA-matched)
44/80 (GA-matched)
6,145/8,076
0.3
1.3
1.3
1.8
1.2
0.20.7
0.394.26
0.72.3
1.03.4
0.43.3
191/626
5.92
0.711.10
2/44
3.97
0.6929.7
189/848
2.43
1.893.13
124/780
1.39
1.01.94
27/60
1.52
0.832.81
CP at age 2 y
CP at age 1 y
10/59
4/18
59/160
CP on register
13/18
CP at 2-y
follow-up
1/13
CP at 1-y
follow-up
7/44
CP diagnosis
on register
CP diagnosis
on register
175/426
Non-CP, breechpresenting
newborns
Non-CP, breechpresenting
newborns
Matched by GA,
birth weight, place
of birth; non-CP
Non-CP
66/317
Non-CP
Non-CP
Non-CP
126/227
RESULTS
Searching PubMed, ClinicalTrials.gov, and Embase
returned a total of 1,874 articles after removal of
duplicates. Fifty-eight articles were considered in-full,
with 13 articles retained for inclusion in the analysis.
Figure 1 outlines the selection process that left 13 articles for inclusion in the analysis. Characteristics of
1171
Remaining articles
n=41
Articles added
(identified in references): n=17
Remaining articles
for review
n=58
Articles included
n=13
CONCLUSION
Overall, cesarean delivery is not associated with
a reduced risk of cerebral palsy, whether the cesarean
be elective or emergency. This meta-analysis does not
support an overall increase or decrease in the risk of
cerebral palsy with cesarean delivery (OR 1.29; 95%
1172
Study or
Subgroup
Cases
Control
Odds Ratio
Odds Ratio
Events Total Events
Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
A. Cesarean delivery and cerebral palsy (overview)
44
2
44
3.0% 3.97 (0.7820.33)
7
Churchill, 1974
646
141
9.6% 0.59 (0.390.88)
33 235
Greenwood, 2004
308
46
8.7% 1.97 (1.143.41)
26 101
Gurbuz, 2006
144
26
18
4.6% 1.30 (0.394.26)
4
Kitchen, 1985
8,076
6,145
18
5.4% 0.82 (0.292.29)
13
Krebs, 1999
280
50
9.5% 1.64 (1.072.53)
56 213
Kulak, 2010
279 1,938 120,793 1,680,503 11.1% 2.17 (1.912.47)
Moster, 2010
234
117
59
8.4% 0.59 (0.331.07)
22
Murphy, 1995
217
51
9.7% 1.54 (1.032.31)
87 271
Nielsen, 2008
1,154
313
587
10.8%
1.87 (1.522.31)
241
OCallaghan, 2011
80
44
8.7% 0.48 (0.280.82)
59 160
OShea, 1998
268
21
153
8.4% 3.36 (1.876.04)
34
Stelmach, 2005
626
191
13
2.1% 0.19 (0.021.47)
1
Svenningsen, 1985
Subtotal (95% CI)
3,810
1,692,580 100.0% 1.29 (0.921.79)
Total events
862
127,940
Heterogeneity: Tau2= 0.25; Chi2
=87.82, df=12 (P< .001); I2=86%
Test for overall effect: Z=1.49 (P=.14)
27.2%
646
22.4%
234
28.4%
1,154
22.0%
268
2,302 100.0%
2.89 (1.316.36)
1.54 (1.032.31)
2.17 (1.712.75)
4.06 (1.719.65)
2.17 (1.582.98)
0.59 (0.390.88)
0.28 (0.140.59)
1.05 (0.771.44)
2.45 (1.165.20)
0.81 (0.411.58)
2.00 (0.844.75)
0.82 (0.292.29)
1.64 (1.072.53)
2.17 (1.912.47)
0.19 (0.021.47)
1.60 (1.052.44)
pressure on and thinning of white matter. The microvasculature of the germinal matrix is frail, and possibly
the potentially less traumatic, less hypoxic, and shorter
cesarean delivery may lead to less neonatal intraventricular hemorrhage and subsequently less cerebral palsy.
Most of the studies in this meta-analysis precede the
0.01 0.1
Favors
interventions
10
100
Favors
control
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1174
25. Moster D, Wilcox AJ, Vollset SE, Markestad T, Lie RT. Cerebral palsy among term and postterm births. JAMA 2010;304:
97682.
32. Kitchen W, Ford GW, Doyle LW, Rickards AL, Lissenden JV,
Pepperell RJ, et al. Cesarean section or vaginal delivery at 24 to
28 weeks gestation: comparison of survival and neonatal and
two-year morbidity. Obstet Gynecol 1985;66:14957.
26. Kulak W, Okurowska-Zawada B, Sienkiewicz D, PaszkoPatej G, Krajewska-Kulak E. Risk factors for cerebral palsy in
term birth infants. Adv Med Sci 2010;55:21621.
33. OShea TM, Klinepeter KL, Dillard RG. Prenatal events and
the risk of cerebral palsy in very low birth weight infants. Am J
Epidemiol 1998;147:3629.
35. Svenningsen NW, Westgren M, Ingemarsson I. Modern strategy for the term breech deliverya study with a 4-year followup of the infants. J Perinat Med 1985;13:11726.
36. Churchill JA, Masland RL, Naylor AA, Ashworth MR. The
etiology of cerebral palsy in pre-term infants. Dev Med Child
Neurol 1974;16:1439.
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