Category 1 cesarean section decision to delivery interval: the causes of delay and impact on neonatal outcomes

Abstract

Objectives: The introduction of cesarean section categorization and recommendations on decision to delivery interval was a major step forward towards standardizing clinical response to obstetric emergencies. The recommended decision to delivery interval (DDI) for category 1 cesarean sections is 30 minutes, however there is a balance to be struck to ensure that reducing fetal hypoxic risk is not at the expense of increasing maternal and fetal morbidity. The aim of the study was to review category 1 cesarean sections, focusing on reasons for delays and neonatal outcomes. Design: The study was conducted as a quality improvement initiative to review the performance of the institution in managing women delivered as category 1 cesarean section between January 2020 and August 2020. Methods: The data was extracted from the operating theatre log book and patient electronic records (Cerner system) and analyzed using SPSS statistics package. Results: There were 577 cases of category 1 Cesarean section undertaken during the study period. The recommended DDI of 30 minutes was achieved in 385/577 (67%) of cases but was exceeded in 192/577 (33%) of cases. The most common indication of category 1 cesarean section was fetal distress (58%). It was noted that significantly more women (88.8%) in the <30-minute group had the decision taken in the labor ward, which is in close proximity to the obstetric theatre. Significantly more women in the <30-minute group had epidural or general anesthesia. Significant delays in the preparation time, transfer time, anesthesia time and delivery time were noted in the >30-minute group. The neonates in the <30-minute group had significantly lower pH and base excess measurements at birth however fewer were admitted to the neonatal intensive care unit. Conclusion: This study has demonstrated that only two thirds of category 1 cesarean deliveries are performed within the 30-minute recommendation. The delays were evident at every stage of the process of performing the cesarean. There are some factors which are not modifiable such as non labor ward transfers. Continued monitoring of category 1 cesarean outcomes is recommended.