Making Elective Caesarean Safer for Infant's Lungs by Reducing Respiratory Distress Using Knee-chest-flexion: a Randomized Controlled Trial

One of the major risk factors for term/near-term infants to develop respiratory distress (RD) is when they are born by elective caesarean section (CS). While this form of RD, commonly diagnosed as transient tachypnea of the newborn (TTN), is considered to be self-limiting, the severity of RD often leads to unexpected admission to the pediatric ward for respiratory support. TTN has also been associated and asthma, bronchiolitis, and other wheezing syndromes later in life. In low- and middle-income settings, where neonatal intensive care resources are limited, a considerable proportion of babies in need of respiratory support do not survive.

There is now strong physiological evidence that RD after elective cesarean section is caused by this greater volume of airway liquid present at birth, which is due to the absence of labor. During labor, uterine contractions contribute to the flexion of the fetus which increases abdominal and transpulmonary pressure. This elevates the diaphragm, resulting in lung liquid loss via nose and mouth. Flexion induced by uterine contractions could be mimicked by manually performing knee-to-chest flexion directly at birth, to achieve expulsion of excess lung liquid. When applying KCF, we essentially bring the newborn back into fetal position, similar to the holding position applied for performing lumbar puncture in neonates.

If this simple intervention has shown to improve neonatal outcome in the clinical setting, KCF will undoubtedly be an extremely cost-effective health care innovation. The maneuver is easy-to-teach to any clinician performing cesarean section. KCF will be performed conform standard gentle care and is likely to be entirely harmless. These advantages (easy-to-teach, no cost, no harm) are relevant across all settings, but may be particularly appealing in low-income settings, where neonatal follow-up and access to neonatal intensive care are often either impossible or limited. It is therefore of outmost importance to test this intervention in a larger institution adapted to performing high-quality clinical research in a low- or middle-income country.

We now hypothesize that performing a knee-to-chest flexion performed directly after birth will reduce the incidence of respiratory distress in term children born by elective caesarean section.

Objective: To test whether performing a knee-to-chest flexion (KCF) manoeuvre directly after elective CS will decrease the incidence of respiratory distress in term infants when compared to standard care.