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

Effect of Anesthetic Modality on Decision-to-Delivery Interval and Maternal-Neonatal Outcomes in Category 2 and 3 Cesarean Deliveries

Background/Objectives: The optimal anesthetic technique for category 2 and 3 cesarean deliveries remains debated, with concerns about impacts on decision-to-delivery interval (DDI) and perinatal outcomes. This study examined the influence of epidural, spinal, and general anesthesia on DDI, surgical and postoperative complications, and neonatal outcomes. Methods: This prospective cohort study at a tertiary perinatology center enrolled parturient women undergoing category 2 and 3 cesarean deliveries. Three DDI phases were assessed for each anesthetic modality: transfer time (decision for cesarean section to admission in the operation room), anesthetic time (admission to incision), and delivery time (incision to delivery of the neonate). The surgical procedure time (incision to closure), neonatal (5 min Apgar score, umbilical artery pH/base excess, neonatal intensive care unit (NICU) admission) and maternal (blood loss, surgical and postoperative complications) outcomes were also analyzed for each group. Results: There were 215 women (122 category 2 and 93 category 3) included. The use of epidural and general anesthesia was associated with significantly shortened DDI compared to spinal anesthesia (p < 0.001). This difference was due prolonged transfer (p < 0.05) and anesthetic times (p < 0.001), respectively. No cases of umbilical artery pH below 7 were observed in any group. No significant differences were observed in the incidence of umbilical artery pH between 7 and 7.10 or in base excess below -12 nmol/L (p = 0.416 and p = 0.865, respectively). NICU admission was higher with both general and spinal anesthesia (p = 0.021), but mainly due to a higher proportion of preterm births, both before the 32nd week (p = 0.033) and between the 32nd and 37th week of pregnancy (p < 0.001). General anesthesia was associated with higher maternal blood loss (p = 0.026) and a higher rate of postoperative complications (p = 0.006). Conclusions: In category 2 and 3 cesarean deliveries, general and epidural anesthesia were associated with shorter DDI compared to spinal anesthesia with no differences in neonatal outcomes. General anesthesia was associated with a higher risk of maternal complications compared to neuraxial anesthetic techniques.

Crash Caesarean Delivery: How to Optimise Decision-to-Delivery Interval by Initiating a Novel Code? A Clinical Audit

Background

Many resource-constrained centres fail to meet the international standard of 30 min of decision-to-delivery interval (DDI) of Category-1 crash caesarean deliveries. However, specific scenarios like acute foetal bradycardia and antepartum haemorrhage necessitate even faster interventions.

Methods

A multidisciplinary team developed a "CODE-10 Crash Caesarean" rapid response protocol to limit DDI to 15 min. A multidisciplinary committee analysed a retrospective clinical audit of maternal-foetal outcomes over 15 months (August 2020-November 2021), and expert recommendations were sought.

Results

The median DDI of twenty-five patients who underwent a "CODE-10 Crash Caesarean delivery" was 13 ± 6 min, with 92% (23/25) of DDIs falling below 15 min. Seven neonates required intensive care for more than 24 h with no maternal or neonatal mortality. DDIs during office and non-office hours were not significantly different (12.5 ± 6 min vs 13 ± 5 min, p = 0.911). Transport delays caused the two instances of DDI > 15 min.

Conclusion

The novel "CODE-10 Crash Caesarean" protocol may be feasible for adoption in a similar tertiary-care setting with appropriate planning and training.

Emergencies in obstetric anaesthesia: a narrative review

We conducted a narrative review in six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. These areas represent significant research published within the last five years, with emphasis on large multicentre randomised trials, national or international practice guidelines and recommendations from major professional societies. Key topics discussed: prevention and management of failed neuraxial technique; role of high-flow nasal oxygenation and choice of neuromuscular drug in obstetric patients; prevention of accidental awareness during general anaesthesia; management of the difficult and failed obstetric airway; current perspectives on the use of tranexamic acid, fibrinogen concentrate and cell salvage; guidance on neuraxial placement in a thrombocytopenic obstetric patient; management of neuraxial drug errors, local anaesthetic systemic toxicity and unusually prolonged neuraxial block regression; and extracorporeal membrane oxygenation use in maternal cardiac arrest.

Learning from maternal deaths due to uterine rupture: review of cases from peri-urban Uganda

BACKGROUND

Maternal deaths from uterine rupture continue to occur globally, with particularly high rates in sub-Saharan Africa. Maternal death reviews have been shown to be an effective part of cohesive strategies to prevent future deaths.

OBJECTIVE

This study aimed to conduct maternal death reviews for all deaths following uterine rupture in the study center, to assess preventability, and to synthesize key learning points that may help to prevent future maternal deaths following uterine rupture.

STUDY DESIGN

Thorough case reviews of all maternal deaths from 2016 to 2018 at the study center (a national referral hospital in urban Uganda) were conducted by trained multidisciplinary panels of obstetricians and midwives. Medical records of women who died following uterine rupture (n=37, 10.6% of all maternal deaths) were extracted for further analysis.

RESULTS

Most maternal deaths due to uterine rupture (36/37, 97%) were preventable, with most having been still potentially preventable after the women reached the study center (24/36, 67%). Obstructed labor was the leading cause of uterine rupture, accounting for 73% (27/37) of cases. Previous cesarean delivery was confirmed in 38% (14/37) of cases. The incidence of grand multiparity was 11% (4/37), and 11% (4/37) were primiparous. Most women (28/37, 76%) died within 24 hours of admission. On arrival at the study center, 19 (51%) were critically ill. Exploratory laparotomy was performed in 54% (20/37) of cases, and a further 35% (13/37) died while awaiting laparotomy. Four women died shortly after arrival at the study center (within 1 hour) and received basic resuscitative treatment; 27% (10/37) of women who died had received antenatal planning or preparation.

CONCLUSION

Most deaths due to uterine rupture were preventable. The key lessons that emerged from the reviews were: (1) careful birth preparation and complication awareness for women with known risk factors, (2) early recognition of obstructed labor, (3) close monitoring of obstetrical interventions known to be associated with uterine rupture, and (4) treating incipient or suspected uterine rupture as a time-critical obstetrical emergency. The recommendations emerging from our narrative reviews are suitable for implementation in low-resource obstetrical settings, where high numbers of deaths involving uterine rupture occur.