Delivery Mode and Neonatal Outcomes in Pregnancies with Fetal Growth Restriction: A Prospective Cohort Study

Background: Fetal growth restriction (FGR) affects 5-10% of pregnancies and remains a leading cause of perinatal morbidity and mortality. The optimal delivery mode for FGR pregnancies remains controversial with conflicting evidence regarding the safety of trial of labor versus elective cesarean delivery. Objective: To prospectively compare neonatal outcomes between elective cesarean, successful vaginal delivery, and emergency cesarean sections in FGR pregnancies delivering at or beyond 34 weeks of gestation. Methods: This prospective cohort study enrolled 90 singleton pregnancies with FGR diagnosed by Delphi consensus criteria, delivering at ≥34 weeks between January 2025 and June 2025. Patients were categorized by delivery mode: elective cesarean section, successful vaginal delivery, or emergency cesarean section. The primary outcome was a composite adverse neonatal outcome including NICU admission, respiratory distress syndrome, birth asphyxia, neonatal hypoglycemia, and low Apgar scores. Statistical analysis employed chisquare tests and multivariable logistic regression. Results: Of 90 patients, 30 underwent elective cesarean delivery, 28 had successful vaginal delivery, and 32 required emergency cesarean section. Emergency cesarean delivery was associated with 3.45-fold increased odds of adverse neonatal outcomes compared to elective cesarean (95% CI: 1.42-8.38, p=0.006). Successful vaginal delivery demonstrated comparable outcomes to elective cesarean (p=0.68). Non-reassuring fetal heart rate was the primary indication for emergency cesarean and associated with the highest adverse outcome rates. Conclusion: Emergency cesarean delivery in FGR pregnancies ≥34 weeks is associated with significantly increased neonatal morbidity. Successful vaginal delivery outcomes are comparable to elective cesarean when appropriately selected, suggesting that trial of labor may be reasonable for carefully selected FGR patients with close monitoring.