Abstract
Objective: To evaluate the impact of an emergency cesarean standard operating procedure (SOP) on the decision-to-delivery interval (DDI) and to determine whether a shorter DDI improves neonatal outcome. Methods: Retrospective analysis of emergency cesareans from 2004 (introduction of the new SOP) to 2009 in a Swiss Level 3 perinatal center. Primary endpoints were the DDI, the pathology-to-decision interval (PDI), the 5 year learning curve, and neonatal and maternal outcome. Results: In the emergency cesarean group (175 women and 188 infants), mean DDI decreased over the observation period from 15 to 9 minutes (mean 10 minutes 41 seconds), and mean PDI from 11 to 6 minutes (mean 8 minutes). Not only did the DDI not exceed 15 minutes in over 90% of cases during the 5 years, but it fell consistently below 10 minutes in the latter stages of the learning curve. Only 2/188 infants had an umbilical artery pH
Highlights
Animal studies show that the risk of irreversible fetal damage is proportional to the duration of pre-delivery asphyxia [1]
The deficits of old standard operating procedure (SOP) were no clearly defined tasks for each individual participating in the emergency caesarean delivery, inconsistent communication about the urgency of caesarean delivery, no documentation of decision-to-delivery interval (DDI) and no written protocol specifying in particular the tasks that would normally be performed, but must be skipped to ensure fast and safe caesarean delivery
The beginning of pathology was validated by the obstetrician deciding on emergency cesarean delivery (e.g. The beginning of fetal bradycardia was timed manually from the electronic CTG (OB TraceVue, Philips); by vaginal bleeding midwife’s call to obstetrician was timed as a beginning of pathologie)
Summary
Animal studies show that the risk of irreversible fetal damage is proportional to the duration of pre-delivery asphyxia [1]. Fetal distress apparent in the cardiotocogram (CTG) in obstetric emergencies such as placental abruption, uterine rupture, umbilical cord prolapse, and maternal respiratory failure prompted the definition, a little over 25 years ago, of a maximum decision-to-delivery (DDI) interval for an endangered child. US guidelines require all hospital obstetric services to be geared to performing emergency delivery within 30 minutes of the decision to operate [2]. UK guidelines recommend delivery as soon as possible, ideally within 30 minutes [3]. Several studies have challenged the totemic 30 minutes [5,6,7], while others have reported that obstetric departments often fail to achieve the target times in practice, for various reasons [8,9,10]
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