Emergency caesarean section during labour: response times and type of anaesthesia

The "30-minute rule" for expedited delivery: fact or fiction?

Initially developed from hospital feasibility data from the 1980s, the "30-minute rule" has perpetuated the belief that the decision-to-incision time in an emergency cesarean delivery should be <30 minutes to preserve favorable neonatal outcomes. Through a review of the history, available data on delivery timing and associated outcomes, and consideration of feasibility across several hospital systems, the use and applicability of this "rule" are explored, and its reconsideration is called for. Moreover, we have advocated for balanced consideration of maternal safety with rapidity of delivery, encouraged process-based approaches, and proposed standardization of terminology regarding delivery urgency. Furthermore, a standardized 4-tier classification system for delivery urgency, from class I, for a perceived threat to maternal or fetal life, to class IV, a scheduled delivery, and a call for further research with a standardized structure to facilitate comparison have been proposed.

Defining the decision-to-delivery interval at caesarean section: narrative literature review and proposal for standardisation

The decision-to-delivery interval is a widely used term at non-elective caesarean section. While the definition may appear self-evident, there is no universally agreed consensus about when this period begins and ends. We reviewed the literature for original research utilising the terms 'decision-to-delivery', 'decision-to-incision' or 'incision-to-delivery' and examined definitions used for decision, delivery, incision, as well as any additional time intervals that were assessed. Our analysis demonstrated an inconsistent non-standardised approach to defining these intervals, which might have clinical practice and medicolegal ramifications. We propose that the decision-to-delivery interval should be defined as follows: the interval between the time at which the senior obstetrician makes the decision that a caesarean section is required and the time at which the fetus (or first fetus in the case of multiples) is delivered. The decision time should ideally be recorded contemporaneously in the medical notes or partogram.

General Versus Regional Anesthesia for Emergency Cesarean Delivery in a High-volume High-resource Referral Center: A Retrospective Cohort Study

Objective

The choice of anesthesia for emergency cesarean delivery (CD) is one of the most important choices to make in obstetric anesthesia. In this study, we examine which type of anesthesia was used for emergency CD in our hospital, and how the choice affected the time from entry to the operation room until incision (TTI), time until delivery (TTD), and maternal/neonatal outcomes.

Methods

Retrospectively, we examined all emergency CD's performed in Shaare Zedek Medical Center between January-December 2018. Results: 1059 patients met the inclusion criteria, of which 7.7% underwent general anesthesia (GA), 36.2% - conversion from labor epidural analgesia to surgical anesthesia, 52% - spinal anesthesia and 4.1% - combined spinal epidural. We did not find a significant difference between the GA and conversion epidural groups in terms of TTI or TTD. Nevertheless, GA was found to be correlated to a high rate of blood-products requirement and ICU admission. The rate of newborns with an APGAR score of less than 7, in both first and fifth second after birth, was significantly higher in the GA group, as well as the need for NICU admission.

Conclusion

This study clearly emphasizes that the TTI are shortest when using GA or conversion of labor epidural analgesia to surgical anesthesia. Meanwhile, GA is also linked to higher rates of admissions to ICU as well as poorer neonatal outcomes compared to the other groups. Additionally, our study uncovered a low rate of GA, and relatively low rate of regional anesthesia failure, which meets the accepted standards.

[Compliance to the color codes protocol according to the indication of cesarean and to the decision-to-delivery interval]

OBJECTIVE

Evaluation of the compliance of the color codes protocol according to the indication of ceasarean section and on the decision-to-delivery interval according to the color code, the operator and the period.

METHODS

This is a retrospective monocentric study including women who had to undergo an emergency cesarean section after 37 weeks of amenorrhea in the Jeanne-de-Flandre hospital between 2015 and 2017. Three groups were created: cesarean section with green code, orange code and red code. We compared population characteristics and obstetrical data, then drew up a reassessed color code and analyzed the correspondence between the initial color code and the reassessed one. Finally, we considered the respect of decision-to-delivery interval according to color code, operator level and period.

RESULTS

Eight hundred and eighty-one patients were included, amongst which 303 (34%) fell into the green c-section, 353 (40%) into the orange c-section and 225 (26%) into the red c-section. In the three groups, there was a significant consistency between the initial color code and the reassessed one, with a kappa agreement test of 95% 0.95 (0.93-0.97). The average decision-to-delivery interval was 37±20min for the green c-section, 20±6min for the orange c-section and 12±3min for the red c-section with a significant respect of the decision-to-delivery interval according to color code P<0.001. The decision-to-delivery interval was similar considering the operator level and the period.

CONCLUSION

In our study, we observed the compliance with color code regarding the indication of ceasarean section and the respect of the decision-to-delivery interval whatever the time of occurrence and the operator.

Decision-to-delivery intervals and perinatal outcomes following emergency cesarean delivery in a Nigerian tertiary hospital

OBJECTIVE

To determine the decision-to-delivery interval (DDI) for emergency cesarean deliveries (CDs) at a tertiary center in Nigeria, to evaluate causes of delay, and to assess the effects of delays on perinatal outcomes.

METHODS

Between September and November 2010, a prospective, observational study was undertaken at University College Hospital, Ibadan. Events that occurred after a decision to perform an emergency CD were recorded. Associations between outcomes and the DDI were analyzed.

RESULTS

Among 235 emergency CDs included, 5 (2.1%) occurred within 30 minutes and 86 (36.6%) within 75 minutes. The mean DDI was 119.2±95.0 minutes. Among CDs with a DDI of more than 75 minutes, logistic factors were the reason for delay in 65 (43.6 %) cases. No significant associations were recorded between DDI and the 5-minute Apgar score, admission to the special-care baby unit, or perinatal mortality (P>0.05 for all). In multivariate analysis, neonates delivered after 75 minutes were significantly less likely to die during the perinatal period than were those delivered within this period (odds ratio 0.13, 95% confidence interval 0.03-0.66; P=0.01).

CONCLUSION

Institutional delays in CDs need to be addressed. However, the DDI could be less important for perinatal outcome than are some other factors, such as the severity of the indication.

Rapidité d’extraction respective des césariennes et des forceps réalisés en urgence

AIM

Comparison of the decision to delivery interval in cases of forceps delivery and in cases of cesarean sections.

MATERIAL AND METHOD

A retrospective analysis was performed on 137 cases of forceps deliver (n = 63) and cesarean section (n = 74) indicated for abnormal fetal heart rhythm. All cases were observed in a level 3 maternity unit between October 2003 and August 2004.

RESULTS

The mean decision-to-delivery interval was significantly shorter in the forceps group (14.84 min +/- 6.54 versus 29.31 min +/- 11.79 p < 0.0001). Maternal and neonatal morbidity were comparable.

CONCLUSION

This study suggest that once the fetal head is engaged, forceps delivery can significantly reduced the decision-to-delivery interval.

Evaluating the decision-to-delivery interval in emergency caesarean sections

OBJECTIVE

To assess the interval between the decision to carry out an emergency caesarean section and delivery, and to determine whether this interval can be shortened.

STUDY DESIGN

A retrospective study was performed in a French maternity hospital over a 6-month period. All caesarean sections performed during labour were included. These caesarean sections were divided into two groups according to Lucas's classification: (1) emergency and urgent caesarean sections and (2) scheduled caesarean sections.

RESULTS

The mean decision--to--delivery interval was 39.5 min in the first group and 55.9 min in the second group. It was mainly influenced by the time taken to get the patient into theatre. The mean decision-to-operating theatre interval accounted for 45.6 and 53.8% of the mean decision-to delivery-interval, respectively.

CONCLUSION

The recommended interval of 30 min is not routinely achieved. Improving communication within the perinatal team could decrease the decision--to--operating theatre interval and should be promoted.

The decision to delivery interval in emergency and non-urgent cesarean sections

OBJECTIVE

The aim of this study was to assess the decision to delivery interval (DDI) in our obstetric unit in comparison to current recommendations.

STUDY DESIGN

A retrospective analysis of all non-elective cesarean sections during a 10 months period in a delivery ward of a university tertiary health care facility was performed. The DDI was compared between emergency and non-urgent cesarean sections.

RESULTS

The DDI was 25.8 +/- 10.8 +/- and 46.2 +/- 19.9 min in the emergency and non-urgent cesareans, respectively (P < 0.01). In the emergency group, 71% delivered within 30 min compared to 35% in the non-urgent group (P < 0.05) and in the emergent-crash group 100% delivered within 30 min compared to 59% in the emergent-non-crash group (P < 0.05). No correlation was found between the DDI and umbilical artery pH or Apgar score at 1 or 5 min in infants of each cesarean group.

CONCLUSION

The proposed 30 min DDI standard was achieved in 100, 71, 47 and 35% of emergent-crash, emergent, emergent-non-crash and non-urgent cesareans sections, respectively.

How long does it take to deliver a baby by emergency Caesarean section?

This audit documented the current range of decision-to-delivery reaction times for 464 emergency Caesarean sections performed in maternity hospitals with differing levels of facilities, and examined the reasons for any perceived delay. The median (with 10th-90th percentile) times from when the decision was made to perform an emergency Caesarean section to the delivery of the child were: 69 (37-114), 54 (28-94) and 42 (17-86) minutes in Level 1, 2 and 3 maternity hospitals respectively when the indication for delivery was urgent. Less urgent emergency Caesarean sections took 70 (42-125), 66 (38-141) and 67 (35-164) minutes respectively. The main perceived reasons for delay in the delivery were staff unavailability in Level 1 hospitals, theatre access in Level 2 hospitals and anaesthetic complications in Level 3 hospitals. Therefore the decision-to-delivery reaction times in the majority of urgent emergency Caesarean sections are, in practice, much longer than the times commonly advocated and are influenced by the facilities and staff available.

Surveys on the use of regional anaesthesia in obstetrics

Regional anaesthetic techniques in obstetrics have gained more and more importance during the last few years. Several surveys published recently show a remarkable increase in caesarean sections performed under regional anaesthesia, in many countries. Furthermore, epidural analgesia has proved to be one of the most effective methods of pain relief during vaginal delivery. Especially in patients at risk of an abdominal delivery, an epidural catheter already in place during labour can be used for consecutive caesarean section without delay and is used as a strong argument in favour of epidural anaesthesia. This article gives an overview of recent surveys of regional anaesthesia in obstetrics.

Anaesthesia for caesarean section--a German survey

BACKGROUND

Anaesthetic practice for caesarean section has changed during the last decades. There is a world-wide shift in obstetric anaesthetic practice in favour of regional anaesthesia. Current data concerning anaesthetic practice in patients undergoing caesarean section from Germany are not available. A comparison with figures from the UK, USA, Norway and other European countries might be of general interest.

METHODS

Questionnaires on the practice of anaesthesia for caesarean section and anaesthetic coverage of the obstetric units were sent to 1178 university, tertiary care, district, community and private hospitals in Germany.

RESULTS

The 532 completed replies of this survey represent 46.9% of the German obstetric units. Most hospitals (42.3%) have delivery rates between 500 and 1000 per year. General anaesthesia is the most common anaesthetic technique for elective (61%), urgent (83%) and emergency caesarean section (98%). Epidural anaesthesia is performed in 23% of scheduled and 5% of non-scheduled caesarean sections, and spinal anaesthesia in 14% and 10% respectively. Acid aspiration prophylaxis before elective caesarean section is used in 68.7% of the departments. The majority of the departments provide a 24-hour anaesthetic coverage; however, in only 6.2% of the units, this service is assigned to obstetric anaesthesia, exclusively.

CONCLUSION

Compared to data from 1978, anaesthetic practice for caesarean section has changed with an increase in regional anaesthesia. However, German anaesthetists prefer general anaesthesia for caesarean section. In contrast, anaesthetists in other countries predominantly use regional techniques, and the difference to German practice is striking. International consensus discussion and recommendations as well as comparable European instruments of quality control in obstetric anaesthesia are desirable.