Very preterm labor (< 28 weeks of delivery, this article specifically refers to 22⁺⁰/₇-25⁺⁶/₇ weeks) has always been a difficulty in obstetric clinical practice. Previously, due to the lack of high-quality data, doctors, pregnant women and families often had difficulty making choices. It is not only wanted to reduce the risk of hypoxia during fetal delivery through cesarean section, but also concerned about the harm of surgery to pregnant women.

The study, jointly conducted by 12 maternal and child medical centers in the United States, specifically targeted singleton pregnant women aged 22⁺⁰/₇-25⁺⁶/₇ weeks, included 277 subjects who received prenatal hormone therapy and neonatal resuscitation, of which 149 were scheduled for cesarean section and 128 chose vaginal trial delivery (9.4% eventually switched to emergency cesarean section), and the maternal and infant outcomes of the two modes of delivery were compared through rigorous data analysis.

1. For the fetus: The two modes of delivery are equally effective

The conclusions of the study were surprising: there was no statistically significant difference between planned cesarean section and vaginal trial delivery in neonatal key outcomes.

▪ Incidence of primary composite outcomes (neonatal death or serious complications, including severe bronchopulmonary dysplasia, grade III-IV intraventricular hemorrhage, necrotizing enterocolitis, etc.): 73.8% in the planned cesarean section group vs 79.7% in the vaginal trial delivery group;

▪ Neonatal mortality rate alone: 31.2% in the planned cesarean section group vs 32.8% in the vaginal trial delivery group;

▪ There is no significant difference in the incidence of other complications such as retinopathy and sepsis between the two groups.

In other words, for ultra-preterm infants at 22-25 weeks, cesarean section does not bring additional survival advantages or fewer sequelae, and the prognosis of the fetus depends more on its own developmental maturity than on the mode of delivery.

2. For mothers: the risk of planned cesarean section is significantly increased

Unlike fetal outcomes, maternal safety risks vary significantly:

▪ Sepsis risk: The planned cesarean section group was 8 times higher than that of the vaginal trial delivery group (6.0% vs. 1.6%);

▪ Postpartum readmission risk: 12 times (8.1% vs 0.8%) in the planned cesarean section, and the reasons for readmission include wound infection, mastitis, endometritis, etc.;

▪ Length of hospital stay: The median in the planned cesarean section group was 6.5 days, which was 2 days more than in the vaginal trial delivery group (median vaginal trial delivery group was 4.0 days);

Although there was no statistical difference in other complications such as postpartum hemorrhage and ICU admission, the incidence of planned cesarean section group was higher than that of the vaginal trial delivery group.

In addition, the incidence of gestational hypertensive disorders was higher in the planned cesarean section group (43.0% vs. 18.8%) and the median birth weight of newborns was lower (620g vs 660g), which also suggests that pregnant women planning cesarean section tend to have more underlying pregnancy complications and are at high risk.

1. When there are no contraindications to vaginal delivery, vaginal trial delivery is a better choice

Studies have made it clear that in the absence of contraindications to vaginal delivery such as placenta previa, placenta accreta, and active herpes, it is more reasonable for pregnant women with ultra-preterm labor at 22-25 weeks to choose vaginal trial delivery. It can not only protect fetal outcomes, but also reduce the risks associated with surgery for the mother.

2. Cesarean section is only suitable for specific medical indications

The core application scenarios of planned cesarean section should be limited to situations with clear surgical indications, such as abnormal fetal position (59.1% of planned cesarean sections in the study are indicated), poor intrauterine condition of the fetus, etc., rather than simply blindly choosing to "make the fetus safer".

3. Individualized decision-making needs to be comprehensively evaluated

Doctors need to formulate a plan based on the specific situation of pregnant women: for pregnant women with complications such as gestational hypertension and fetal growth restriction, they need to weigh the risk of disease control and delivery; For fetal distress during vaginal trial delivery, timely conversion to emergency cesarean section is still a necessary rescue method.

This study fills the evidence gap in the choice of ultra-preterm delivery mode and provides a reference for clinical decision-making. The advantages of this are multicentre data, strict inclusion and exclusion criteria, and a focus on both mother-infant outcomes, and the conclusions are highly credible.

However, there are also certain limitations to the study, such as retrospective secondary analysis, some data are missing, and potential confounding factors such as fetal weight and maternal BMI are not included. Prospective studies with larger sample sizes are needed to further validate the conclusions in the future.

The choice of delivery method for ultra-preterm birth at 22-25 weeks does not need to worry too much about "which is better for the fetus", and scientific evidence shows that there is little difference between the two. More rational decision-making should focus on "maternal safety": when there are no clear indications for surgery, vaginal trial delivery should be preferred, which can significantly reduce the risk of sepsis and postpartum readmission to the hospital; Planned cesarean section should be considered only if medically necessary.