Background
There is a paucity of published clinical data to guide obstetric decision‐making regarding mode of birth at extreme prematurity.

Aims
To evaluate whether neonatal survival or maternal outcomes were affected by the decision to perform a caesarean section (CS) between 23 + 0 and 26 + 6 weeks’ gestation.

Materials and Methods
A single‐centre retrospective cohort study of all liveborn infants born with a plan for active resuscitation at 23–26 weeks’ gestation was performed. Descriptive and multivariate logistic regression analyses compared outcomes after vaginal birth and CS. Subgroup analyses of nonfootling breech presentations, multiple pregnancies and singleton pregnancies in spontaneous preterm labour were performed.

Results
Outcomes for 625 neonates delivered by 540 mothers were analysed. A total of 300 (48%) neonates were born vaginally and 325 (52%) by CS. Mode of birth was not associated independently with survival for any multivariate analysis; gestational age at birth was an independent predictor across all analyses. Adverse maternal outcomes were documented in 112 (21%) pregnancies; the rate of severe maternal complications was low. Maternal morbidity was not affected by mode of birth.

Conclusions
Mode of birth did not affect neonatal survival or the rate of maternal morbidity for deliveries at 23–26 completed weeks’ gestation.