Antenatal Corticosteroids Before Elective Term Cesarean Section
Prophylactic corticosteroids are NOT routinely indicated for healthy term pregnant women undergoing elective lower-segment cesarean section at ≥37 weeks of gestation. 1, 2
Evidence-Based Recommendation
The European Society of Cardiology explicitly states that steroids should not be used routinely for elective cesarean delivery at term. 2 This recommendation is supported by multiple lines of evidence:
Why Steroids Are Not Recommended at Term (≥37 weeks)
Insufficient evidence of benefit: The single high-quality randomized controlled trial (942 women) showed uncertain effects on respiratory distress syndrome (RR 0.34,95% CI 0.07–1.65) and transient tachypnea (RR 0.52,95% CI 0.25–1.11), with confidence intervals crossing the line of no effect. 3
Low baseline risk: The overall incidence of respiratory morbidity at term is only 2.8%, making the absolute benefit minimal even if relative risk reduction exists. 4
Potential harms outweigh uncertain benefits: Exposing term neonates to corticosteroids carries risks of neonatal hypoglycemia (93% of cases are mild but still require monitoring), and long-term neurodevelopmental effects remain uncertain despite ongoing follow-up studies. 1, 5
The Late Preterm Exception (37⁰–38⁶ weeks)
Corticosteroids MAY be considered for elective cesarean section at ≤38 weeks gestation to reduce neonatal respiratory morbidity, but this is a weak recommendation with limited evidence. 1
This applies specifically to cesarean sections scheduled between 37 and 38 completed weeks, not at 39+ weeks. 1
The regimen is betamethasone 12 mg intramuscularly in two doses, 24 hours apart. 1, 5
Critical caveat: The ACOG guideline suggests this only when cesarean is planned at ≤38 weeks, recognizing that respiratory morbidity risk decreases substantially after 38 weeks. 1
Algorithmic Approach for Decision-Making
For Elective LSCS at ≥39 weeks:
For Elective LSCS at 37⁰–38⁶ weeks:
Consider betamethasone only if:
Do NOT administer if:
For Elective LSCS at <37 weeks (Late Preterm):
- Administer betamethasone if delivery is anticipated within 7 days and patient meets high-risk criteria (GRADE 1A recommendation). 1, 5
Common Pitfalls to Avoid
Overuse in low-risk term patients: The ACOG explicitly warns against administering steroids to women with low likelihood of delivery before 37 weeks, as this exposes infants to unnecessary risks without proven benefit. 5, 2
Use in diabetic patients: This is an absolute contraindication at any gestational age due to severe neonatal hypoglycemia risk. 1, 5, 2
Assuming term benefit based on preterm data: The robust evidence for corticosteroid benefit at 24–34 weeks (reducing RDS by 29%, mortality by 40%) does NOT extrapolate to term gestations where baseline respiratory morbidity is already low. 5, 6
Delaying necessary delivery: Never delay a medically indicated cesarean section to complete a steroid course at term—the risks of delay outweigh any theoretical respiratory benefit. 1
Strength of Evidence
The recommendation against routine use at term is based on:
Moderate-certainty evidence showing probable reduction in NICU admission (RR 0.45) but low to very low-certainty evidence for the clinically important outcomes of RDS and TTN. 3
The single trustworthy RCT (942 participants) had high risk of performance and detection bias due to lack of blinding, and wide confidence intervals that include both benefit and harm. 3
Long-term follow-up from the Antenatal Steroids for Term Elective Caesarean Section trial (799 children, median age 12.2 years) found no difference in behavioral, cognitive, or developmental outcomes, but this does not exclude subtle effects. 7
In summary: For a healthy term pregnancy with elective LSCS at ≥37 weeks, do not administer prophylactic corticosteroids. The evidence does not support routine use, and the potential harms (particularly neonatal hypoglycemia and uncertain long-term neurodevelopmental effects) outweigh the minimal and uncertain respiratory benefits at this gestational age. 1, 2, 3