Decision-to-delivery interval: Is 30 min the magic time? What is the evidence? Does it work?

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.

A specific protocol to shorten the decision-to-delivery interval for emergency caesarean section

The achievement of recommended decision-to-delivery interval (DDI) of ≤30 minutes in emergency caesarean section (CS) is relatively low in developing countries. This study was aimed to compare DDI in emergency CS before and after the implementation of a specific care process improvement protocol, called 'code blue'. A total of 300 women underwent emergency CS were included; 150 consecutive cases before (during 2015-2016) and the other 150 consecutive cases after (during 2017-2018) 'code blue' implementation. Timing of decision-to-delivery process was compared. The results showed that median DDI was significantly shorter after 'code blue' implementation (22 vs. 52.5 minutes, p<.001). DDI of ≤30 minutes was achieved in 80% of the women under 'code blue' compared to 8% before implementation (p<.001). Significant improvements were observed regardless of decision time. Pregnancy and neonatal outcomes were comparable between the two periods. The implementation of 'code blue' protocol for emergency CS results in significantly shorter DDI and other time intervals.Impact StatementWhat is already known on this subject? Achievement of recommended decision-to-delivery interval (DDI) of ≤30 minutes in emergency caesarean section is relatively low in developing countries. Various setting-specific care improvement processes have been reported to shorten DDI.What do the results of this study add? A multidisciplinary care improvement process ('code blue') that developed according to specific evidence and based on a hospital's context can significantly shorten DDI as well as other time intervals in women requiring emergency CS.What are the implications of these findings for clinical practice and/or further research? The 'code blue' protocol could be used as a model for other hospitals and health care settings to develop their own specific quality improvement process in order to shorten DDI for emergency CS. Collaboration and communication between all staff members could help in better identification of significant barriers as well as development of appropriate solutions. Further studies are also needed to determine whether the shortened DDI could improve neonatal outcomes.

Obstetric Emergencies requiring Rapid response team activation: A retrospective cohort study in a high-risk tertiary care centre

OBJECTIVE

The purpose of this study was to better understand obstetric codes requiring rapid response team (RRT) activation by examining their incidence, indications, team response and patient outcomes.

METHODS

This was a retrospective study in peripartum women who required activation of "Code 77 (C77)" (obstetric emergency), "Code Blue (CB)" (cardiopulmonary compromise) or "Code Omega (CO)" (massive transfusion) during hospitalization during January 2014-May 2018. Hospital database and health records were interrogated to identify and review cases. Data on code characteristics, resuscitative measures, and maternal/ neonatal outcomes were collected.

RESULTS

147 codes were identified (C77, n=110; CO, n=25; CB, n=12) during the study period, with an incidence of 1:203 deliveries (C77 - 1:271 deliveries, CO - 1:1,194 deliveries and CB - 1:2,488 deliveries). The common indications for C77 were cord prolapse (33%) and fetal bradycardia (32%), and for CO and CB were postpartum hemorrhage (84%) and cardiac arrest (42%), respectively. Most (67%) codes occurred afterhours. The median (IQR) decision-to-delivery interval (DDI) was 8 (5, 15) min after C77. Emergency cesarean delivery (CD) was performed after 57% of obstetric emergencies and general anesthesia was administered in 63% of CDs. Maternal and neonatal mortality rates were 0.68% and 7%, respectively. Major maternal morbidity was seen in 33% cases. Debrief was documented in 4% codes.

CONCLUSION

RRT activation was required more commonly in C77 than in CO or CB. Their response time and DDIs were rapid. Mortality was low, however, one-third parturients had major morbidity. We suggest closer patient monitoring, immediate availability of resources, and appropriate documentation and debriefing.

A retrospective review of 10-year trends in general anesthesia for cesarean delivery at a university hospital: the impact of a newly launched team on obstetric anesthesia practice

Background

The indications for general anesthesia (GA) in obstetric settings, which are determined in consideration of maternal and fetal outcome, could be affected by local patterns of clinical practice grounded in unique situations and circumstances that vary among medical institutions. Although the use of GA for cesarean delivery has become less common with more frequent adoption of neuraxial anesthesia, GA was previously chosen for pregnancy with placenta previa at our institution in case of unexpected massive hemorrhage. However, the situation has been gradually changing since formation of a team dedicated to obstetric anesthesia practice. Here, we report the results of a review of all cesarean deliveries performed under GA, and assess the impact of our newly launched team on trends in clinical obstetric anesthesia practice at our institution.

Methods

Our original database for obstetric GA during the period of 2010 to 2019 was analyzed. The medical records of all parturients who received GA for cesarean delivery were reviewed to collect detailed information. Interrupted time series analysis was used to evaluate the impact of the launch of our obstetric anesthesia team.

Results

As recently as 2014, more than 10% of cesarean deliveries were performed under GA, with placenta previa accounting for the main indication in elective and emergent cases. Our obstetric anesthesia team was formed in 2015 to serve as a communication bridge between the department of anesthesiology and the department of obstetrics. Since then, there has been a steady decline in the percentage of cesarean deliveries performed under GA, decreasing to a low of less than 5% in the latest 2 years. Interrupted time series analysis revealed a significant reduction in obstetric GA after 2015 (P = 0.04), which was associated with decreased use of GA for pregnancy with placenta previa. On the other hand, every year has seen a number of urgent cesarean deliveries requiring GA.

Conclusions

There has been a trend towards fewer obstetric GA since 2015. The optimized use of GA for cesarean delivery was made possible mainly through strengthened partnerships between anesthesiologists and obstetricians with the support of our obstetric anesthesia team.

Decision-delivery intervals: Impact of a colour code protocol for emergency caesareans

OBJECTIVE

Assess the impact of implementation by simple distribution of a "colour code" protocol for emergency caesareans on the course over time of the "decision-delivery interval" (DDI) and neonatal outcome.

DESIGN

Observational study in 26 maternity units of the AURORE perinatal network, conducted between October 1, 2017, and April 30, 2018. Each maternity ward́ was supposed to prospectively include 20 consecutive cases of caesareans performed either as an emergency, that is, as a code orange, or an extreme emergency, that is, code red. We compared the DDIs observed in 2017 to those in 2007 according to the degree of emergency, the maternity unit level of care, and their adherence to the protocol. Neonatal outcome in 2007 and 2017, assessed from laboratory and clinical indicators, was also compared, overall and according to the degree of emergency.

RESULTS

The DDI was significantly lower in 2017 (n = 478) than in 2007 (n = 447), regardless of the degree of emergency and the level of care (p < 0.0001). In 2017, all code red caesareans were performed in less than 15 min in level 3 maternity units compared with 73 % (p = 0.039) in 2007. Fewer than 20 % of the caesareans in the 2007 study period were performed in less than 15 min in level 1 and 2 maternity units. Today, this is the case for 83 % of these caesareans in level 2 units (p < 0.001) and 36 % in level 1 (p = 0.01). In 2017, code orange caesareans were performed in less than 30 min in 96 % of cases in level 3 units, 67 % in level 2, and 33 % in level 1, compared respectively with 67 % (p = 0.015), 25 % (p < 0.0001) and 16 % (p = 0.0003) in 2007. We did not observe any difference in the neonatal outcome between 2007 and 2017 or as a function of the DDI expected based on the caesarean colour code.

CONCLUSION

The implementation of the colour code protocols was associated with an improved DDI and better adherence to the recommendations in all 26 maternity units in this perinatal network.

Anesthesia for Urgent Cesarean Section

Cesarean section (CS) is a common surgical procedure worldwide. The anesthesiologist is responsible, together with obstetrician and neonatologist, for safe perioperative management. A continuum of risk exists for urgent CS. The decision-to-delivery interval is an important audit tool, to ensure international standards are upheld and good outcomes for mother and neonate are achieved. Urgent CS may be performed under either GA or RA, with benefits and risks attributable to each. Specific clinical scenarios require an individualized approach to anesthesia, including hemorrhage, hypertensive disorders, cardiac disease, the difficult airway and fetal compromise. Ongoing training is integral to the provision of safe anesthesia.

Birth asphyxia following delayed recognition and response to abnormal labour progress and fetal distress in a 31-year-old multiparous Malawian woman

Reducing neonatal mortality is one of the targets of Sustainable Development Goal 3 on good health and well-being. The highest rates of neonatal death occur in sub-Saharan Africa. Birth asphyxia is one of the major preventable causes. Early detection and timely management of abnormal labour progress and fetal compromise are critical to reduce the global burden of birth asphyxia. Labour progress, maternal and fetal well-being are assessed using the WHO partograph and intermittent fetal heart rate monitoring. However, in low-resource settings adherence to labour guidelines and timely response to arising labour complications is generally poor. Reasons for this are multifactorial and include lack of resources and skilled health care staff. This case study in a Malawian hospital illustrates how delayed recognition of abnormal labour and prolonged decision-to-delivery interval contributed to birth asphyxia, as an example of many delivery rooms in low-income country settings.

Sudden severe fetal compromise at a planned home birth – a case of umbilical cord prolapse

Background

Sudden severe fetal compromise during labor is usually associated with fetal bradycardia often due to sudden emergencies such as abruptio placentae, cord prolapse, disruption of the umbilical cord, shoulder dystocia, tetanic contractions or uterine rupture.

Case presentation

We report on a case of sudden severe fetal compromise due to umbilical cord prolapse in a patient with a planned home birth. Cord prolapse and thick meconium stained fluid were diagnosed at a planned home birth at the time of spontaneous rupture of fetal membranes with the cervix 3 cm dilated. An ambulance was called, and the patient was transferred by ambulance to the nearby hospital where the baby was delivered about 60 min after the diagnosis of the cord prolapse. Neonatal resuscitation was unsuccessful, and the newborn was declared dead.

Conclusion

Our case shows that sudden severe fetal compromise during labor and delivery can happen to even low-risk patients. When it happens at home, delay of delivery can lead to neonatal injury or death. Women who express an interest in a planned home birth must be informed of potential risks of sudden severe fetal compromise leading to neonatal injury or death when it occurs in a planned home birth and when transport to the hospital unavoidably delays timely medical interventions and delivery of the newborn.

Distance from Home Birth to Emergency Obstetric Services and Neonatal Outcomes: A Cohort Study

INTRODUCTION

Little is known about the relationship between distance from hospital services and the outcomes of planned home births. We examined whether greater driving distance from a hospital with continuous cesarean capability was associated with a higher risk of adverse neonatal outcome among individuals who were planning to give birth at home.

METHODS

Using an intention-to-treat analysis, we conducted a population-based cohort study of 11,869 individuals who planned to give birth at home in Ontario, Canada, between April 1, 2012, and March 31, 2015. We used postal codes to determine the driving time from maternal residence to the closest hospital offering level 2 or higher maternity care services (ie, hospital with continuous cesarean birth capability). We used log binomial regression analysis to compare the outcomes of individuals who planned a birth more than a 30-minute drive from a level 2 hospital with those of individuals whose births were planned to occur within 30 minutes. We adjusted for maternal age, parity, gestational age, season, and maternal material deprivation quintile.

RESULTS

We found no statistically significant difference in the rates of 5-minute Apgar scores less than 7 (adjusted relative risk [aRR], 1.02; 95% CI, 0.95-1.10; P = .58), perinatal mortality, meconium aspiration syndrome, and emergency medical service usage. Neonates born to individuals who planned to give birth at a greater distance from a hospital had a lower rate of neonatal intensive care unit admission (aRR, 0.6; 95% CI, 0.44-0.81; P = .001).

DISCUSSION

We found no increased risk of adverse neonatal outcomes for births that were planned to occur more than 30 minutes from a hospital. Our findings can be considered, along with individual risk factors and contextual factors, in decision making about the choice of home birth for individuals who live more than half an hour from a hospital with cesarean capacity.