Evaluation of decision-to-delivery interval in emergency cesarean section: A 1-year prospective audit in a tertiary care hospital

Decision To Delivery Time and Its Predictors Among Mothers Who Underwent Emergency Cesarean Delivery At Selected Hospitals of Northwest Ethiopia, 2023: Prospective Cohort Study

Background

The decision to delivery time is the interval between the decision and the childbirth by emergency caesarean delivery. The Royal College of Obstetricians and Gynecologists and the American College of Obstetricians and Gynecologists recommend that the decision to delivery time interval is less than 30 min. Additionally, the decision to delivery time varies across institutions and countries.

Objective

The aim of this study was to determine the decision to delivery time and its predictors among women who underwent emergency cesarean delivery at selected hospitals of Northwest Ethiopia, 2023.

Methods

An institutional-based prospective cohort study was conducted at selected hospitals of Northwest Ethiopia, among women who underwent emergency cesarean delivery from November 1 to January 30, 2023. A total of 285 participants were enrolled, and data collected using structured and pre-tested questionnaires. A systematic sampling technique was used. Data were entered into Epi-Data version 4.6 and then exported to STATA 15 for further analysis. The log rank test was utilized to compare group differences. The time is estimated by using the Kaplan-Meier curve and Cox proportional-hazard regression analysis was carried out to determine the predictors.

Results

From 285 participants, 56 (21.8%) women delivered within the recommended 30 min. The overall median survival time was undetermined and the restricted mean survival time was 48.9 min (95% CI: 47.4-50.5). The average decision to delivery time is affected among women who hesitate to accept consent (AHR: 0.17, 95% CI: 0.02-1.25), cord prolapses (AHR: 1.36, 95% CI: 0.46-3.94), rank of surgeon (AHR: 0.42. 95% CI: 0.42-1.08), no free operation room table (AHR: 0.27, 95% CI: 0.28-0.94), regional anesthesia (AHR: 0.56, 95% CI: 0.25-1.28), and use of a bladder flap (AHR: 0.33, 95% CI: 0.16-0.85).

Conclusion

Overall decision to delivery times among women who underwent emergency cesarean section at selected hospitals were longer than the recommended time.

Effect of in situ simulation training for emergency caesarean section on maternal and infant outcomes

BACKGROUND

Emergency caesarean section (ECS) is an effective method for rapid termination of pregnancy and for saving maternal and foetal life in emergencies. Experts recommend that the interval from decision of operation to the decision to delivery interval (DDI) should be shortened as much as possible. Studies have shown that improving communication skills among staff by performing simulation drills shortens DDI, thus reducing the occurrence of adverse obstetric events and protecting maternal and child safety. In situ simulation (ISS) training is a simulation-based training approach for clinical team members conducted in a real-world clinical setting. In August 2020, Anhui Maternal and Child Health Hospital began ISS training on the rapid obstetric response team (RRT) in our hospital area for emergency caesarean section. This study aimed to investigate the effect of implementing in situ simulation training for emergency caesarean section on maternal and child outcomes by comparing maternal and child-related data on emergency caesarean section in two hospital areas.

METHODS

Data on cases of emergency caesarean delivery implemented in two hospital districts from August 2020 to August 2022 were collected: 19 in the untrained group and 26 in the training group. The two groups were compared concerning the interval from the decision of operation to the decision to delivery interval (DDI), the interval from the decision of operation to the initiation of skin incision, the interval from skin incision to the decision to delivery interval, and the neonatal situation.

RESULTS

Primary outcome comparison: The training group had a significantly shorter interval between the DDI compared to the untrained group (8.14 ± 3.13 vs. 11.03 ± 3.52, P = 0.006). Secondary outcomes comparison: The training group had a significantly shorter interval between the decision to cut skin compared to the untrained group (6.45 ± 2.21 vs. 9.95 ± 4.02, P = 0.001). However, there was no significant difference in the interval between cutting skin and infant delivery between the two groups (2.24 ± 0.08 vs. 2.18 ± 0.13, P > 0.05). Additionally, the Apgar score at 1 min after birth was higher in the training group compared to the untrained group (7.29 ± 2.38 vs. 6.04 ± 1.46, P < 0.05).

CONCLUSIONS

The DDI for emergency caesarean section procedures can be significantly shortened, and neonatal Apgar scores at 1 min improved by implementing in situ simulation training for emergency caesarean section in obstetric rapid response teams. In situ simulation training is an effective tool for training in emergency caesarean section procedures and is worth promoting.

Decision to delivery interval for emergency caesarean section in Eastern Uganda: A cross-sectional study

INTRODUCTION

The decision to delivery interval is a key indicator of the quality of obstetric care. This study assessed the decision to delivery interval for emergency cesarean sections and factors associated with delay.

METHODS

We conducted a cross-sectional study between October 2022 and December 2022 in the labor ward at Mbale regional referral hospital. Our primary outcome variable was the decision to delivery interval defined as the time interval in minutes from the decision to perform the emergency caesarean section to delivery of the baby. We used an observer checklist and interviewer administered questionnaire to collect data. Stata version 14.0 (StataCorp; College Station, TX, USA) was used to analyze the data.

RESULTS

We enrolled 352 participants; the mean age was 25.9 years and standard deviation (SD) ±5.9 years. The median (interquartile range) decision to delivery interval was 110 minutes (80 to 145). Only 7/352 (2.0%) participants had a decision to delivery time interval of ≤30 minutes. More than three quarters 281 /352 (79.8%) had a decision to delivery interval of greater than 75 minutes. Emergency cesarean section done by intern doctors compared to specialists [Adjusted Prevalence Ratio (aPR): 1.26; 95% CI: (1.09-1.45)] was associated with a prolonged decision to delivery interval.

CONCLUSION

The average decision to delivery interval was almost 2 hours. Delays were mostly due to health system challenges. We recommend routine monitoring of decision to delivery interval as an indicator of the quality of obstetric care.

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.

Evaluation of decision to delivery interval and its effect on feto-maternal outcomes in Category-I emergency cesarean section deliveries in Phuentsholing General Hospital, 2020: A retrospective cross-sectional study

Background and Aims

When there is an immediate threat to maternal or fetal life, it is recommended to deliver within 30 min of the decision to have favorable perinatal outcomes. However, there is no data on the delivery intervals for Category-I emergency cesarean section in Bhutan. The study evaluated the decision to delivery interval (DDI) and its effect on perinatal and maternal outcomes in Category-I emergency cesarean section.

Methods

A retrospective cross-sectional study was conducted at the Phuentsholing General Hospital, Bhutan, from January 1, 2020 to December 31, 2020. Mothers who underwent Category-I emergency cesarean section were included. The demographic variables, patient transfer time, anesthesia time, operation time, DDI, and maternal and perinatal outcomes were recorded in a standard proforma. The data were analyzed using SPSS version 23.

Results

Of 78 Category-I emergency cesarean sections, only 23 (29.5%) of the cases were able to perform within 30 min of the DDI. The median (interquartile range) DDI was 37 (30-44) min. More time was taken by anesthetists to administer anesthesia (20 [15-8] min). Fetal distress (40, 51.3%) was the commonest indication. The longest DDI was around 39 min for prolonged labor, and the shortest was 26 min for failed instrumental delivery. Over half of the newborns delivered more than 30 min of DDI had low APGAR scores (25, 32.1%) at 1 min and meconium was present (23, 29.5%). Intensive care was required in 11 (14.1%), of which there was 1 (1.3%) neonatal death.

Conclusion

The Category-I emergency cesarean sections performed within recommended DDI of 30 min were much less. The main delay was due to the longer time taken for the patient transfer and time taken by the anesthetists to administer anesthesia. Perinatal outcomes were favorable when the deliveries were conducted within 30 min of DDI.

A Retrospective Review of Decision to Delivery Time Interval for Foetal Distress at a Central Hospital

Purpose

The aim of this study was to describe the trajectory of emergency caesarean deliveries for foetal distress at Chris Hani Baragwanath Academic Hospital (CHBAH).

Patients and Methods

A retrospective, contextual, descriptive study, using consecutive convenience sampling was done reviewing all the records of emergency caesarean deliveries for foetal distress at CHBAH in February 2019 until a minimum sample size of 385 was reached.

Results

During the study period, a total of 617 caesarean deliveries were done, of which 572 (92.7%) were emergencies. Foetal distress accounted for 395 (69.1%) of the emergency caesarean deliveries. No emergency caesarean delivery for foetal distress conformed to the 30-minute DDI and the mean (SD) DDI was 411 (291) minutes. The mean (SD) 5-minute and 10-minute Apgar scores were 8.4 (1.6) and 9.6 (1.3), respectively. There was a significant difference between the type of anaesthetic (general or neuraxial), with those receiving general anaesthesia having shorter anaesthetic start to cut time (p=0.0110). However, those delivered following neuraxial anaesthesia had better 5-minute (p=0.0002) and 10-minute (p=0.0175) Apgar scores.

Conclusion

This study showed that a DDI of 30-minutes, was not achieved at CHBAH during the study period. Most babies diagnosed with foetal distress pre-delivery had 5-minute and 10-minute Apgar scores inconsistent with this diagnosis. This over-diagnosis of foetal distress in some cases could have led to delays in delivery of babies who had actual foetal distress and where a 30-minute DDI could have improved outcome.

Using machine learning to identify quality-of-care predictors for emergency caesarean sections: a retrospective cohort study

OBJECTIVES

Emergency caesarean sections (ECS) are time-sensitive procedures. Multiple factors may affect team efficiency but their relative importance remains unknown. This study aimed to identify the most important predictors contributing to quality of care during ECS in terms of the arrival-to-delivery interval.

DESIGN

A retrospective cohort study. ECS were classified by urgency using emergency categories one/two and three (delivery within 30 and 60 min). In total, 92 predictor variables were included in the analysis and grouped as follows: 'Maternal objective', 'Maternal psychological', 'Fetal factors', 'ECS Indication', 'Emergency category', 'Type of anaesthesia', 'Team member qualifications and experience' and 'Procedural'. Data was analysed with a linear regression model using elastic net regularisation and jackknife technique to improve generalisability. The relative influence of the predictors, percentage significant predictor weight (PSPW) was calculated for each predictor to visualise the main determinants of arrival-to-delivery interval.

SETTING AND PARTICIPANTS

Patient records for mothers undergoing ECS between 2010 and 2017, Nordsjællands Hospital, Capital Region of Denmark.

PRIMARY OUTCOME MEASURES

Arrival-to-delivery interval during ECS.

RESULTS

Data was obtained from 2409 patient records for women undergoing ECS. The group of predictors representing 'Team member qualifications and experience' was the most important predictor of arrival-to-delivery interval in all ECS emergency categories (PSPW 25.9% for ECS category one/two; PSPW 35.5% for ECS category three). In ECS category one/two the 'Indication for ECS' was the second most important predictor group (PSPW 24.9%). In ECS category three, the second most important predictor group was 'Maternal objective predictors' (PSPW 24.2%).

CONCLUSION

This study provides empirical evidence for the importance of team member qualifications and experience relative to other predictors of arrival-to-delivery during ECS. Machine learning provides a promising method for expanding our current knowledge about the relative importance of different factors in predicting outcomes of complex obstetric events.

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.

Decision-to-delivery interval and neonatal outcomes for category-1 caesarean sections during the COVID-19 pandemic

General anaesthesia is known to achieve the shortest decision‐to‐delivery interval for category‐1 caesarean section. We investigated whether the COVID‐19 pandemic affected the decision‐to delivery interval and influenced neonatal outcomes in patients who underwent category‐1 caesarean section. Records of 562 patients who underwent emergency caesarean section between 1 April 2019 and 1 July 2019 in seven UK hospitals (pre‐COVID‐19 group) were compared with 577 emergency caesarean sections performed during the same period during the COVID‐19 pandemic (1 April 2020–1 July 2020) (post‐COVID‐19 group). Primary outcome measures were: decision‐to‐delivery interval; number of caesarean sections achieving decision‐to‐delivery interval < 30 min; and a composite of adverse neonatal outcomes (Apgar 5‐min score < 7, umbilical arterial pH < 7.10, neonatal intensive care unit admission and stillbirth). The use of general anaesthesia decreased significantly between the pre‐ and post‐COVID‐19 groups (risk ratio 0.48 (95%CI 0.37–0.62); p < 0.0001). Compared with the pre‐COVID‐19 group, the post‐COVID‐19 group had an increase in median (IQR [range]) decision‐to‐delivery interval (26 (18–32 [4–124]) min vs. 27 (20–33 [3–102]) min; p = 0.043) and a decrease in the number of caesarean sections meeting the decision‐to‐delivery interval target of < 30 min (374/562 (66.5%) vs. 349/577 (60.5%); p = 0.02). The incidence of adverse neonatal outcomes was similar in the pre‐ and post‐COVID‐19 groups (140/568 (24.6%) vs. 140/583 (24.0%), respectively; p = 0.85). The small increase in decision‐to‐delivery interval observed during the COVID‐19 pandemic did not adversely affect neonatal outcomes.

Magnitude and trends in socio-economic and geographic inequality in access to birth by cesarean section in Tanzania: evidence from five rounds of Tanzania demographic and health surveys (1996-2015)

Background

Majority of maternal deaths are avoidable through quality obstetric care such as Cesarean Section (CS). However, in low-and middle-income countries, many women are still dying due to lack of obstetric services. Tanzania is one of the African countries where maternal mortality is high. However, there is paucity of evidence related to the magnitude and trends of disparities in CS utilization in the country. This study examined both the magnitude and trends in socio-economic and geographic inequalities in access to birth by CS.

Methods

Data were extracted from the Tanzania Demographic and Health Surveys (TDHSs) (1996–2015) and analyzed using the World Health Organization’s (WHO) Health Equity Assessment Toolkit (HEAT) software. First, access to birth by CS was disaggregated by four equity stratifiers: wealth index, education, residence and region. Second, we measured the inequality through summary measures, namely Difference (D), Ratio (R), Slope Index of Inequality (SII) and Relative Index of Inequality (RII). A 95% confidence interval was constructed for point estimates to measure statistical significance.

Results

The results showed variations in access to birth by CS across socioeconomic, urban-rural and regional subgroups in Tanzania from 1996 to 2015. Among the poorest subgroups, there was a 1.38 percentage points increase in CS coverage between 1996 and 2015 whereas approximately 11 percentage points increase was found among the richest subgroups within same period of time. The coverage of CS increased by nearly 1 percentage point, 3 percentage points and 9 percentage points among non-educated, those who had primary education and secondary or higher education, respectively over the last 19 years. The increase in coverage among rural residents was 2 percentage points and nearly 8 percentage points among urban residents over the last 19 years. Substantial disparity in CS coverage was recorded in all the studied surveys. For instance, in the most recent survey, pro-rich (RII = 15.55, 95% UI; 10.44, 20.66, SII = 15.8, 95% UI; 13.70, 17.91), pro-educated (RII = 13.71, 95% UI; 9.04, 18.38, SII = 16.04, 95% UI; 13.58, 18.49), pro-urban (R = 3.18, 95% UI; 2.36, 3.99), and subnational (D = 16.25, 95% UI; 10.02, 22.48) absolute and relative inequalities were observed.

Conclusion

The findings showed that over the last 19 years, women who were uneducated, poorest/poor, living in rural settings and from regions such as Zanzibar South, appeared to utilize CS services less in Tanzania. Therefore, such subpopulations need to be the central focus of policies and programmes implemmentation to improve CS services coverage and enhance equity-based CS services utilization.

Evaluation of decision to delivery time interval and its effect on feto-maternal outcomes and associated factors in category-1 emergency caesarean section deliveries: prospective cohort study

Background

Category-1 emergency caesarean section delivery is the commonly performed surgical procedure in pregnant women associated with significant mortality and morbidity both in the mother and fetus. The decision to delivery time interval is recommended to be less than 30 min by the Royal College of Obstetricians and Gynecologists as well as the American College of Obstetricians and Gynecologists. This study was designed to evaluate the decision to delivery time interval and its effect on feto-maternal outcomes and the associated factors during category-1 emergency caesarean section deliveries.

Method

A prospective observational cohort study was conducted from March to May 2018 at the University of Gondar Comprehensive Specialized Hospital obstetrics Operation Theater and postnatal ward. A total of 163 clients who were undergone category-1 emergency caesarean section were included in this study. Statistical analysis was performed using SPSS version 20 (IBM Corporate). Bivariate and multivariate logistic regression with a 95% confidence interval was used to determine the association of decision to delivery time interval with predictor variables and feto-maternal outcomes.

Results

Only 19.6% of women had a decision to delivery time interval below 30 min. The average decision to delivery time interval was 42 ± 21.4 min, the average time from the decision of category-1 emergency caesarean section arrival to the operation theater was 21.58 ± 19.76 min and from theater to delivery of anesthesia was 11.5 ± 3.6 min. Factors that were associated with prolonged decision to delivery time interval were: time taken to collect surgical materials (AOR = 13.76, CI = 1.12–168.7), time taken from decision and arrival to the operation theater (AOR = 0.75, CI = 0.17–3.25) and time taken from arrival at the operation theater to the immediate start of skin incision (AOR = 0.43, CI = 0.28–0.65).

Conclusion

Delivery was not achieved within the recommended time interval in the majority of category-1 emergency caesarean sections. The average decision to delivery time interval was longer than the recommended time but it did not affect feto-maternal outcomes.

Simulation training is useful for shortening the decision-to-delivery interval in cases of emergent cesarean section

OBJECTIVE

We examined the effect of simulation training for medical staff on the decision-to-delivery interval (DDI) in cases of emergent cesarean delivery and the effect of a shortened DDI on maternal and neonatal outcomes.

MATERIAL AND METHODS

Our hospital is a tertiary perinatal center. As the simulation training was performed in March 2014, the study population was divided into two groups: pretraining group (November 2011-March 2014, 29 months: n = 15) and post-training group (April 2014-August 2016, 29 months: n = 35).

RESULTS

The DDI was significantly shorter in the post-training group than in the pretraining group (p = .009). In particular, the decision-to-entering the operating room interval was significantly shorter in the post-training group than in the pretraining group (p = .003). The umbilical artery pH was significantly better in post-training group than in the pretraining group (p = .019). Furthermore, the umbilical artery pH was significantly improved by simulation training only in "irreversible" cases (p = .012).

CONCLUSIONS

The DDI was significantly shortened by introducing simulation training. We also demonstrated a beneficial effect of the simulation training on the umbilical artery pH, especially in "irreversible" cases, without increasing the rate of maternal adverse outcome.