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Revista da Associação Médica Brasileira

Print version ISSN 0104-4230On-line version ISSN 1806-9282

Rev. Assoc. Med. Bras. vol.61 no.4 São Paulo July/Aug. 2015

https://doi.org/10.1590/1806-9282.61.04.296 

GUIDELINES IN FOCUS

Cesarean on request

Cesariana a pedido

Sergio F. de Toledo1 

Ricardo Simões1  2 

Luca S. Bernardo2 

Wanderley M. Bernardo2 

Antônio J. Salomão Salomão1 

Edmund C. Baracat1 

Febrasgo, Sociedade Brasileira de Anestesiologia

1Federação Brasileira das Associações de Ginecologia e Obstetrícia (Febrasgo)

2Guidelines Project, Associação Médica Brasileira


The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize procedures to assist the reasoning and decision-making of doctors.

The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Introduction

The rates of C-sections without medical or obstetric indication have increased substantially in the last decades, especially in developing countries. Many factors contribute to this increase, being the mother-requested cesarean delivery a contributing factor (D).1

There is a major debate about the implementation of C-sections performed at the mother’s request without any established medical indication, and safety, cost, maternal autonomy, maternal and professional satisfaction, and ethics constitute important factors under discussion. These days, the practice of cesarean section on request constitutes a very important issue but, unfortunately, there is a lack of scientific studies to guide medical practice. Women over the decades became independent, modern and active in various professions, excelling compared to men. Their autonomy allows them to enjoy their own choices, including those related to their own body. In developed countries, they can choose whether or not to carry out an initial pregnancy, plastic surgery procedures, or even bariatric surgery.

Thus, detailed scientific studies in the context of evidence-based medicine are essential.

Objective

To prepare a recommendation evaluating the risks and benefits involved in the practice of cesarean delivery on maternal request and C-section without medical indication, compared to the planned vaginal delivery.

Methods

The evidence used for analysis of the risks and benefits involved in the practice of cesarean delivery on maternal request and C-section without medical indication was obtained according to the following steps: preparation of the clinical question, structuring of the question, search for evidence, critical evaluation and selection of evidence.

Clinical question

Are nulliparous or multiparous women undergoing cesarean section, on request or without medical indication in term pregnancies, at increased risk of maternal and fetal complications compared to those undergoing planned vaginal delivery?

Structured question

The clinical question is structured according to the P.I.C.O. components: (P [patient]; I [intervention]; C [comparison]; O [outcome]).

  • P: pregnancy to term;

  • I: cesarean section on maternal request;

  • C: vaginal deliver;

  • O: maternal, perinatal and neonatal morbidity and mortality.

Bases of scientific data consulted

The scientific databases consulted were: PubMed-Medline and Cochrane. Manual search from revisions references (narrative or systematic) was also performed.

Strategies for search of evidence

PubMed-Medline

Strategy: (cesarean* OR (cesarean sections OR delivery, abdominal OR abdominal deliveries OR deliveries, abdominal OR caesarean section OR caesarean sections OR abdominal delivery OR C-section (ob) OR C section (ob) OR C-sections (ob) OR postcesarean section)) AND (request OR patient preference OR demand OR medical indication OR medical indications).

Cochrane

Strategy: cesarean section AND request.

Studies retrieved (4/15/2014) (Table 1)

TABLE 1 Number of studies retrieved with the search strategies used for each scientific database 

Database Number of studies
Primary
PubMed-Medline 1,482
Cochrane 54

Inclusion criteria for studies retrieved

Selection of studies, assessment of titles and abstracts obtained from the search strategy in the consulted databases was conducted by two researchers with skills in the preparation of systematic reviews, both independent and blinded, strictly observing the inclusion and exclusion criteria previously established. All potentially relevant studies were identified. Whenever the title and the summary were not enlightening, researchers sought the full article.

Study design

Narrative reviews, case reports, case series and studies presenting preliminary results were excluded from the assessment. Systematic reviews and meta-analyzes were used with the basic purpose of recovering references that perhaps had been lost at first, from the initial search strategy. Only comparative nonrandomized studies (strength of evidence 2B and 2C) were included.

P.I.C.O. components

  • Patient: nulliparous or multiparous patients undergoing cesarean section on maternal request or without medical indication, at term, pre- or intra-labor, and women undergoing planned vaginal delivery at term.

  • Intervention: cesarean section on maternal request or cesarean delivery without medical indication.

  • Comparison: patients undergoing planned vaginal delivery.

  • Outcome: the outcomes were divided into maternal outcomes, newborn outcomes and emergency cesarean. Maternal outcomes include: maternal death, bleeding complications, infectious complications, wound complications, complications in breastfeeding. Bleeding complications were defined in the study as bleeding ≥ 1,000mL, need for blood transfusion after delivery, need for curettage due to placental persistence, anemia, prolonged vaginal bleeding and hysterectomy caused by bleeding. Maternal infectious complications are defined as urinary tract infections, endometritis and sepsis. Wound complications were classified as wound infection, dehiscence or pain. Complications in breastfeeding are defined as mixed feeding or feeding with formula only. Newborn outcomes include: Apgar score lower or equal to 7, asphyxia, respiratory complications, infection, and need for admission to neonatal ICU. Asphyxia was defined as pH of venous blood or blood cord lower than 7.0. Respiratory complications were defined according to studies of respiratory distress syndrome of the newborn, use of CPAP, need for ventilation, and dyspnea or tachypnea.

Language

The authors included studies available in Portuguese, English, French or Spanish.

According to publication

Only studies with full text available were considered for critical assessment.

Studies selected in the first assessment

Using the search strategy described, 1,482 studies were retrieved. Out of these, which were reviewed based on title, only 295 articles included the subject cesarean delivery on maternal request or C-section without medical indication, and thus 1,187 studies were excluded. Of the 295 studies, only 73 were selected for full text review, being considered for final evaluation 9 comparative studies (observational cohorts) that met the criteria for inclusion and exclusion (Flowchart 1).

FLOWCHART 1 Study selection. 

Evidence selected in critical evaluation and exhibition of results

The studies considered for full text reading were critically assessed according to inclusion and exclusion criteria, study design, P.I.C.O., language and availability of the full text.

TABLE 2 Critical assessment script for randomized controlled trials (checklist) 

Study data Reference, study design, Jadad, strength of evidence Sample size calculation Estimated differences, power, significance level, total number of patients
Patient selection Inclusion and exclusion criteria Patients Recruited, randomized, prognostic differences
Randomization Description and blinded allocation Patient follow-up Time, losses, migration
Treatment protocol Intervention, control and blinding Analysis Intention to treat, analyzes of intervention and control
Outcomes considered Primary, secondary, measuring instrument of the outcome of interest Result Benefit or harm in absolute data, benefit or harm on average

TABLE 3 Selection process 

Type of publication Included
Nonrandomized comparative studies 92-10

TABLE 4 Maternal complications 

C-section without medical indication n Vaginal delivery n p
Average gestational age (SD)
Karlström 2013 38.40 (±0.73) 5877 39.81 (±1.17) 12936 <0,0000001
Crowther 2012 38.8 (±0.7) 1098 40 (±1.1) 1225 <0,0000001
Liu 2012 40.2 (±1.0) 22462 40.1 (±1.0) 409242 <0.0000001
Larsson 2011 38 247 40 294 -
Dahlgren 2009 38.56 (±0.91) 1046 39.29 (±1.11) 38021 <0,0000001
C-section without indication n RA PC Vaginal delivery n RA PV RRA(-) ARA(+) CI
Maternal death
Crowther 2012 0 1098 0.0 0 1225 0.0 0.0 -
Souza 2010 2 2685 0.07% 230 212847 0.11% -0.03% -0.14, 0.07
Dahlgren 2009 0 1046 0.0 0 38021 0.0 0.0 -
Bleeding complications (%)
Karlström 2013 579 (9.9) 5877 9.85% 935 (6.8) 13774 6.79% 3.06% 2.19, 3.93
Crowther 2012 9 (0.8) 1098 0.82% 29 (2.4) 1225 2.37% -1.55% -2.55, -0.54
Larsson 2011 25 (10) 247 10.12% 41 (14) 294 13.95% -3.82% -9.28, 1.64
Souza 2010 27 (1.0) 2685 1.01% 3613 (1.4) 256518 1.41% -0.40% -0.78, -0.02
Wang 2010 12 (4.0) 301 3.99% 2 (0.6) 301 0.66% 3.32% 0.93, 5.71
Dahlgren 2009 3 (0.29) 1046 0.29% 123 (0.32) 38021 0.32% -0.04% -0.37, 0.29
Schindl 2003 0 (0.0) 147 0.0 17 (1.8) 903 1.88% -1.88% -2.77, -0.99
Infectious complications (%)
Karlström 2013 148 (2.5) 5877 2.52% 155 (1.1) 13774 1.12% 1.39% 0.95, 1.83
Larsson 2011 8 247 3.24% 8 294 2.72% 0.52% -2.37, 3.40
Wang 2010 7 (2.3) 301 2.33% 3 (1.0) 301 0.99% 1.33% -0.71, 3.37
Dahlgren 2009 1 (0.1) 1046 0.10% 104 (0.27) 38021 0.27% -0.18% -0.37, 0.02
Schindl 2003 0 (0.0) 147 0.0 1 (0.1) 903 0.11% -0.11% -0.33, 0.11
Wound complications (%)
Crowther 2012 18 (1.6) 1098 1.64% 13 (1.1) 1225 1.06% 0.58% -0.37, 1.53
Larsson 2011 0 (0.0) 247 0.0 1 (0.3) 294 0.34% -0.34% -1.01, 0.32
Wang 2010 31 301 10.3% 32 301 10.6% -0.33% -5.22, 4.56
Dahlgren 2009 10 (0.96) 1046 0.96% 189 (0.5) 38021 0.50% 0.46% -0.13, 1.05
Breastfeeding complications (%)
Karlström 2013 73 (1.2) 5877 1.24% 32 (0.2) 13774 0.23% 1.01% 0.71, 1.30
Liu 2012 2317 (10.3) 22462 10.32% 31211 (7.6) 409242 7.63% 1.35% 2.28, 3.09

P values < 0.05 and confidence intervals that exclude null values are in bold.

TABLE 5 Emergency C-section 

  C-section without indication n RAPC Vaginal delivery n RAPV RRA(-) ARA(+) CI
Karlström 2013 0 5877 0.0 838 13774 6.08% -6.08% -6.48, -5.68
Crowther 2012 109 (9.9) 1098 9.93% 367 (30) 1225 29.96% -20.0% -23.15, -16.92
Larsson 2011 25 (10) 247 10.12% 45 (15.4) 294 15.31% -5.18% -10.76, 0.39
Dahlgren 2009 0 (0.0) 1046 0.0 5580 (14.7) 38021 14.68% -14.7% -15.03, -14.32
Schindl 2003 0 (0.0) 147 0.0 93 (10.3) 903 10.3% -10.3% -12.28, -8.32

P values < 0.05 and confidence intervals that exclude null values are in bold.

TABLE 6 Newborn complications 

  C-section without indication n Vaginal delivery n p
Average birth weight (SD)
Karlström 2013 3558 (±448) 5877 3665 (±467) 12936 <0,0000001
Crowther 2012 3462 (±451) 1098 3571 (±495) 1225 <0,0000001
Liu 2012 3438 (±393) 22462 3332 (±375) 409242 <0.0000001
Larsson 2011 3339 247 3617 294 <0,001
Dahlgren 2009 3383.8 (±415.96) 1046 3531.4 (±441.85) 38021 <0,0000001
  C-section without medical indication n RA PC Vaginal delivery n RA PV RRA (-) ARA (+) CI
Apgar score ≤ 7 (%)
Karlström 2013 38 (0.6) 5877 0.65% 252 (1.8) 13774 1.83% -1.18% -1.48, -0.88
Crowther 2012 0 (0.0) 1098 0.0 1 (0.1) 1225 0.08% -0.08% -0.24, 0.08
Larsson 2011 Average -   Average -      
Dahlgren 2009 0 (0.0) 1046 0.0 182 (0.48) 38021 0.48% -0.48% -0.55, -0.41
Respiratory complications (%)
Karlström 2013 159 5877 2.7% 153 13774 1.11% 1.59% 1.14, 2.04
Crowther 2012 2 1098 0.18% 1 (0.1) 1225 0.08% 0.10% -0.20, 0.40
Dahlgren 2009 91 1046 8.7% 2900 (7.63) 38021 7.63% 1.07% -0.65, 2.80
Schindl 2003 1 147 0.68% 0 (0.0) 903 0.0 0.68% -0.65, 2.01
Asphyxia (%)
Karlström 2013 3 (0.1) 5877 0.05% 78 (0.5) 13774 0.56% -0.51% -0.65, -0.38
Crowther 2012 1 (0.1) 1098 0.09% 6 (0.5) 1225 0.49% -0.40% -0.83, 0.03
Dahlgren 2009 1 (0.1) 1046 0.10% 51 (0.13) 38021 0.13% -0.04% -0.23, 0.15
Infection (%)
Karlström 2013 29 (0.5) 5877 0.11% 111 (0.8) 13774 0.0% 0.11% -0.11, 0.33
Crowther 2012 1 (0.1) 1098 0.09% 4 (0.3) 1225 0.33% -0.23% -0.60, 0.13
Dahlgren 2009 1 (0.1) 1046 0.09% 29 (0.08) 38021 0.08% 0.02% -0.17, 0.21
Admission to neonatal ICU (%)
Crowther 2012 4 (0.4) 1098 0.36% 7 (0.6) 1225 0.57% -0.21% -0.76, 0.34
Larsson 2011 13 (5.3) 247 5.26% 15 (5.1) 294 5.10% 0.16% -3.59, 3.91
Souza 2010 33 (1.2) 2685 1.23% 4532 (1.8) 256869 1.76% -0.53% -0.95, -0.11
Wiklund 2007 5 99 5.05% 12 237 5.06% -0.01% -5.15, 5.12
Schindl 2003 0 (0.0) 147 0.0 1 (0.1) 903 0.11% -0.11% -0.33, 0.11

P values < 0.05 and confidence intervals that exclude null values are in bold.

Results of the clinical situations are displayed in Tables 4, 5 and 6.

References related to the studies included are shown in Table 3, and are also presented in the section References.

After applying the inclusion and exclusion criteria, the evidence selected in the search and defined as randomized controlled trials (RCT) were subjected to an appropriate checklist for critical assessment (Table 2). Critical assessment of RCTs allows to classify them according to the Jadad score, so that Jadad < 3 trials are considered inconsistent (B), and those with scores ≥ 3, consistent (A). For critical analysis of non-randomized studies, among them prospective observational studies, the authors used the Newcastle-Ottawa scale.8

For results with available evidence, wherever possible, the following specific items are defined: population, intervention, outcomes, the presence or absence of benefit and/or damage and controversies.

Cost issues will not be included in the results.

The results will be presented preferably in absolute data, absolute risk, number needed to treat (NNT), or number needed to harm (NNH), and occasionally in mean and standard deviation.

Statistical analysis

The measures of effectiveness or damage expressed in absolute numbers were analyzed using the difference in absolute risk, adopting a confidence interval of 95%. For statistically significant results, the number needed to treat to benefit (NNT) and the number needed to treat to harm (NNH) were calculated. The meta-analysis was performed using RevMan 5 (Review Manager, Cochrane Collaboration, 2008) software.

Heterogeneity

Inconsistencies among the clinical trials were evaluated for heterogeneity using chi-square test (Chi2) and quantified through I2 test. Values above 50% were considered significant.

Results

Evidence selected

The main reasons for the exclusion of works were: the unavailability of the full text; nonrandomized comparative studies with different study design; studies that included preterm fetuses (gestational age <37 weeks), or those using only the estimated weight of the fetus as a criterion for inclusion. The graphics of the meta-analysis relating to the works included in the assessment are shown in the Appendix.

The average gestational age is significantly lower in the group of cesarean delivery with no indication as compared to the planned vaginal delivery group in four of the five studies evaluating this outcome (Table 4) (B).3-6,9 The mean birth weight is assessed in five studies, and in one work, only the mean weight is significantly higher in the cesarean group without indication (Table 5) (B).3-6,8

Effect of cesarean section on maternal request or without indication on maternal mortality

Three studies evaluate maternal mortality (B);2-4 however, only one study has events for this outcome (B).8 The study shows an absolute risk reduction of maternal mortality of 3.0% in favor of cesarean section on maternal request or without indication; however, this decrease is not significant (95CI: -0.14 to 0.07; Table 4).

Effect of cesarean section on maternal request or without indication on bleeding complications

Seven studies assessed maternal bleeding complications after delivery (B).2,3-8 Based on simple averages, the rate of bleeding complications in the group of cesarean section on maternal request without medical indication is 5.8 versus 1.3% in the group of vaginal delivery, demonstrating an increase in the absolute risk of 4.5%. Thus, 22 patients need to undergo cesarean section for a bleeding complication to occur (NNH=22). In the meta-analysis, the results of studies have shown that cesarean section on maternal request or without medical indication increases by 1.0% (95CI: 0.01 to 0.02; p<0.00001; I2=96%; Figure 1.1) the absolute risk of bleeding complications compared to planned vaginal delivery.

Effect of cesarean section on maternal request or without indication on infectious complications

The rate of infectious complications demonstrated by simple average in the group of cesarean delivery on maternal request or without indication is 2.2 versus 0.5% in the group of planned vaginal delivery. The development of infectious complications after cesarean delivery was evaluated in five studies (B),3-8 which, in the meta-analysis demonstrated an increase of 1.0% (95CI: 0.01 to 0.01; p<0.00001; I2=98%; Figure 1.2) in absolute risk of infectious complications in the cesarean delivery group.

Effect of cesarean section on maternal request or without indication on wound complications

Four studies (B)3-7 evaluate the incidence of wound complications after cesarean or vaginal delivery. The incidence of wound complications obtained by simple average in the group of cesarean delivery on maternal request or without indication is 2.2%, while in the planned vaginal delivery group, it is 0.6%. However, there is no significant increase or decrease (95CI: -0.00 to 0.01; p=0.50; I2=0%; Figure 1.3) in the risk of wound complications between the groups according to the assessment made by the meta-analysis.

Effect of cesarean section on maternal request or without indication on breastfeeding

The studies (B)5,9 assessed the association between cesarean section on maternal request or without indication and complications in breastfeeding. The simple average of all the studies revealed that the rate of breastfeeding complications in the group of cesarean delivery on maternal request is 8.4 versus 7.4% in the group of planned vaginal delivery. Therefore, 100 patients are required to undergo cesarean delivery without medical indication so that one can present breastfeeding complications (NNH=100). The results demonstrate that cesarean delivery on maternal request or without indication is associated with an increase of 2.0% (95CI: 0.02 to 0.03; p<0.00001; Figure 1.4) in the risk of complications related to exclusive breastfeeding.

Incidence of emergency cesarean section without indication and planned vaginal delivery

Five studies (B)3-6,8 evaluate the progression to emergency cesarean delivery from cesarean delivery on maternal request or without indication and vaginal delivery, so that the emergency cesarean delivery rate in the cesarean delivery group maternal request is 1.6%, while in the group of planned vaginal delivery, the rate is 12.8% based on the evaluation of the simple average of all studies.

Vaginal delivery has a significant increase of 9.0% (95CI: -0.09 to -0.9; p<0.00001; I2=100%; Figure 2) in the absolute risk of progression to emergency cesarean delivery compared to cesarean delivery without indication as demonstrated by the meta-analysis.

Effect of cesarean section on maternal request or without indication on the Apgar score

Three studies (B)3-5 evaluated the influence of cesarean delivery on maternal request on Apgar score. The group of cesarean delivery on maternal request has a lower incidence of Apgar score reduction compared to the group of planned vaginal delivery (0.47 versus 0.82%), according to the evaluation of average for all the groups. Therefore, 286 patients are required to undergo cesarean delivery without medical indication in order to one have one newborn with no reduction in Apgar score (NNT=286) (Table 6). The meta-analysis shows significant reduction in the absolute risk of 1.0% (95CI: -0.01 to -0.01; p<0.00001; I2=98%; Figure 3.1).

Effect of cesarean section on maternal request or without indication on the occurrence of neonatal asphyxia

In the group of cesarean delivery on maternal request, the rate of neonatal asphyxia (B)3-5 is 0.06%, while the rate in the group of planned vaginal delivery is 0.25%, based on the average of all studies. There is no significant reduction in absolute risk regarding the rate of asphyxia between the two groups (95CI: -0.01 to -0.00; p=0.0002; I2=88%; Figure 3.2) (Table 6), although there is a difference shown in the meta-analysis chart.

Effect of cesarean section on maternal request or without indication on respiratory complications

Four studies (B)3-5,8 assessed the respiratory complications of the newborn related to cesarean delivery on maternal request or without indication. The average obtained from all studies demonstrate that respiratory complications in the cesarean group total 3.1 versus 5.7% in the group of planned vaginal delivery (Table 6). However, the meta-analysis shows that the cesarean delivery on maternal request is associated with a significant increase of 1.0% (95CI: 0.01 to 0.02; p<0.00001; I2=96%; Figure 3.3) in the absolute risk of the development of respiratory complications.

Effect of cesarean section on maternal request or without indication on the rate of newborn infection

The average of infectious complications (B)3-5 in the group of cesarean delivery on maternal request is 0.4%, while in the group of planned vaginal delivery the rate of infection is 0.3% (Table 6). Although there are differences in favor of cesarean delivery, the meta-analysis shows no significant reduction in the absolute risk of infection between the two groups (95CI: -0.00 to -0.00; p=0.02; I2=74%; Figure 3.4).

Effect of cesarean section on maternal request or without indication on the rate of admission to neonatal ICU

The average hospital stay in neonatal ICU obtained from studies (B)2,4,6,8,10 evaluating this outcome is 1.2% in the cesarean group, versus 1.8% in the group of planned vaginal delivery (Table 6). Despite the fact that the group of cesarean delivery on maternal request has a lower rate of neonatal ICU hospitalization compared to the group of planned vaginal delivery, based on the simple average of all studies, the meta-analysis shows that the reduction is not significant (95CI: -0.01 to -0.00; p=0.84; I2=0%, Figure 3.5).

Final recommendations

The authors conclude that cesarean delivery on maternal request or without indication increases the risk of bleeding, infectious, breastfeeding and respiratory complications for the newborn. There was a reduction in the risk of emergency cesarean section and Apgar score ≤ 7 compared to planned vaginal delivery. Cesarean delivery on maternal request does not present significant increases or reductions in maternal mortality, post surgical wound complications, neonatal asphyxia, neonatal infection, and admission to neonatal ICU.

Based on this information and in the absence of maternal and/or fetal indications for resolution by cesarean delivery, a vaginal birth should be safe and suitable for recommendation to a pregnant woman. If, after the explanation of the risks and benefits of each obstetric resolution, showing every detail of the risks in each mode of delivery, the patient still rejects vaginal delivery, cesarean section should not be performed before 39 weeks of gestation. The cesarean delivery should be discouraged for patients who want more offspring, because of the risk of placenta accreta, low insertion of placenta and hysterectomies in subsequent births; C-section should not be recommended as a painless option of delivery over vaginal delivery, either.

In this context, based on maternal request for cesarean section, the authors propose that the physician should try to know more deeply the personal values and preferences of the pregnant patient, addressing them in a process of shared decision-making (A)11 (D).12,13 Thus, the declared and underlying motivations of the patient can be investigated, including the intense fear of childbirth, also known as tokophobia, and other factors associated with cesarean section on maternal request: previous complicated pregnancy; adverse experience in labor or delivery; anxious or avoidant personality traits; or history of sexual abuse (D)14,15(B).16,17

Studies indicate that women undergoing cesarean at their own request have a higher frequency of psychopathological manifestations and psychiatric diseases. Specifically, a recent meta-analysis identified prevalence in the community of three percent for postpartum post-traumatic stress disorder (A).18 Cesarean section may be regarded by some patients as a resource to alleviate the suffering derived from anxious or depressive symptoms. Therefore, it is recommended that the doctor is also aware of the need for evaluation and treatment by a psychiatrist and/or psychologist with expertise in perinatal mental health.

Appendix

Meta-analysis charts

FIGURE 1.1 Bleeding complications. 

FIGURE 1.2 Infectious complications. 

FIGURE 1.3 Wound complications. 

FIGURE 1.4 Breastfeeding complications. 

FIGURE 2 Emergency C-section. 

FIGURE 3.1 Decrease in Apgar score. 

FIGURE 3.2 Neonatal asphyxia. 

FIGURE 3.3 Respiratory complications. 

FIGURE 3.4 Newborn infection. 

FIGURE 3.5 Admission to neonatal ICU. 

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Conflict of interest: none

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