What are the causes of newborn death during or immediately after a cesarean section?

Causes of Newborn Death During or After Cesarean Section

The primary causes of newborn death during or immediately after cesarean section are birth asphyxia (accounting for approximately 61% of early neonatal deaths), prematurity (18%), low birth weight (8%), and septicemia, with hypothermia and failed resuscitation representing critical preventable factors. 1, 2

Major Causes of Neonatal Mortality

Birth Asphyxia (Perinatal Hypoxia)

• Birth asphyxia is the leading cause of early neonatal death, responsible for 28.7-61% of perinatal deaths following cesarean delivery. 1, 3, 2
• Asphyxia results from failure to establish spontaneous respirations immediately after delivery, leading to oxygen deprivation, ATP depletion, anaerobic metabolism, and acidosis. 4, 5
• Approximately 5% of term newborns require assisted ventilation at birth, and delayed resuscitation leads to irreversible neurologic damage or death. 6
• Critical pitfall: The 5-minute Apgar score ≥7 was present in 50% of infants who died from birth asphyxia, making it a poor surrogate marker. 2

Prematurity and Low Birth Weight

• Prematurity accounts for 18-24.8% of perinatal deaths, with nearly 90% of neonatal mortality occurring in low birth weight infants. 3, 2
• Low birth weight (defined as <3rd centile for gestational age) contributes to 8% of early neonatal deaths. 2
• At 30 weeks gestation, neonatal survival is approximately 92%, but in-hospital mortality remains 8.1% with significant morbidity including 43.8% respiratory distress syndrome and 6.3% cerebral palsy risk at 5 years. 7

Septicemia and Infections

• Septicemia is the most common cause of perinatal death in some series, followed by asphyxia and prematurity. 1
• Bacterial infections account for 2-5.6% of perinatal deaths, with cord infection representing a significant source of morbidity. 1, 3

Hypothermia

• Hypothermia is associated with increased neonatal morbidity and death across all gestational ages. 6
• Operating room temperatures of 21-25°C may not maintain neonatal normothermia without active warming measures. 6
• Body temperature must be maintained between 36.5°C and 37.5°C after birth through admission and stabilization. 6

High-Risk Obstetric Conditions Leading to Neonatal Death

Placental Abruption

• Abruptio placentae carries high stillbirth rates and is associated with fetal hemorrhage, coagulopathy (fibrinogen <200 mg/dL), and irreversible fetal distress requiring emergency cesarean delivery. 7, 1

Cord Complications

• Umbilical cord prolapse with sustained bradycardia represents an irreversible cause of fetal distress requiring immediate cesarean delivery. 8
• Transverse lie increases risk of cord complications and perinatal mortality. 1

Congenital Malformations

• Congenital abnormalities account for 8-14.6% of perinatal deaths. 3, 2

Critical Preventable Factors

Failed or Inadequate Resuscitation

• All settings performing cesarean delivery must have immediate capacity for neonatal resuscitation with appropriate equipment, staffing, and skills. 6, 8
• Approximately 85% of term babies initiate spontaneous respirations within 10-30 seconds; an additional 10% respond to drying and stimulation; the remaining 5% require assisted ventilation. 6
• Improper resuscitation of a severely depressed newborn increases the chance of permanent neurologic sequelae or death. 5

Immediate Cord Clamping

• Immediate cord clamping should be restricted to infants requiring immediate resuscitation or when placental circulation is not intact. 6
• Delayed cord clamping for at least 1 minute at term decreases anemia and improves neurodevelopmental outcomes. 6
• In preterm infants, delayed cord clamping for at least 30 seconds reduces need for transfusion, intraventricular hemorrhage, and necrotizing enterocolitis. 6

Iatrogenic Complications

• Routine suctioning of the airway or gastric aspiration should be avoided; secretions should be cleared only if obstructing the airway. 6
• Routine neonatal supplementation with oxygen outside resuscitation may be associated with harm and is not recommended. 6
• High oxygen levels (100% FiO₂) can increase short-term mortality; start with FiO₂ ≤50% for term newborns and titrate to achieve saturation of 90-95%. 9

Sudden Unexpected Postnatal Collapse (SUPC)

• SUPC is a rare but potentially fatal event occurring in 2.6-133 per 100,000 newborns, with 73% occurring in the first 2 hours of life. 6
• Risk factors include unsupervised skin-to-skin care in prone position, primiparous mothers, and maternal sedation or distraction. 6
• Continuous staff observation with frequent vital sign recording is essential during the first 2 hours after cesarean delivery. 6

Essential Immediate Interventions to Prevent Death

Temperature Management

• Immediate drying and covering of the infant's head reduces heat losses. 6
• Use exothermic heaters, transwarmer mattresses, plastic wraps/bags, and caps for preterm infants. 6

Respiratory Support

• Support the infant to regain body control and gently stimulate for breath or cry. 6
• Avoid 100% oxygen; use FiO₂ ≤50% initially and titrate using pulse oximetry. 9

Monitoring Requirements

• Apgar scores must be assessed and documented at 1,5, and 10 minutes after delivery. 6
• High-risk situations (resuscitation required, low Apgar scores, late preterm, difficult delivery, maternal medications) require continuous monitoring. 6