ABSTRACT: To prevent neonatal hypoxic-ischemic morbidities, a nonreassuring fetal heart rate (NRFHR) during labor is considered a major indication for prompt delivery (≤30 minutes) via emergency cesarean section (ECS). The 30-minute rule is commonly used for decision-to-delivery interval when ECS is performed. This study was undertaken to assess the effect of a departmental program designed to shorten the decision-to-delivery interval for ECS for NRFHR on maternal and neonatal outcomes.
The medical records of all patients who underwent ECS during 2009 to 2013 were reviewed and included women who delivered at 24 to 42 weeks’ gestation by ECS for NRFHR as the only indication. In March 2011, a departmental protocol to shorten the decision-to-delivery interval for ECS for NRFHR was implemented including the following: (1) documentation was needed for precise time intervals in addition to recording the decision-to-delivery interval; (2) general anesthesia for patients without regional anesthesia was preferred; (3) each case was debriefed for identification of delaying obstacles; and (4) for each case, a strategy was targeted to overcome each delaying obstacle in subsequent cases. The parturients were categorized as those who delivered before (−27 months; period 1 [P1]) and after (+27 months; period 2 [P2]) program implementation. Decision-to-delivery interval and maternal and neonatal outcomes were compared between the 2 periods.
Of 20,366 women who delivered, 4507 (22.1%) had CS, of which 738 (16.4%) were ECS because of NRFHR. After exclusions, 593 ECS cases were analyzed, with 292 ECSs performed during P1 and 301 during P2. The 2 groups did not differ in demographic or obstetric characteristics. Mean DDI was 21.7 ± 9.1 minutes in P1 versus 12.3 ± 3.8 minutes in P2 (P < 0.001). Overall, 82.5% of ECSs in P1 were performed with a decision-to-delivery interval of less than 30 minutes compared with 99.3% in P2 (P < 0.001). The rate of ECS with a decision-to-delivery interval of less than 20 minutes was 56.8% in P1 compared with 93.7% in P2 (P < 0.001). Mean surgery duration did not differ between the groups. In a linear multivariate regression model examining decision-to-delivery interval as a dependent variable, and general anesthesia, spinal anesthesia, and period of the study as independent variables, P2 (P < 0.001) and general anesthesia (P = 0.013) were significant independent predictors for shorter decision-to-delivery interval. Composite maternal intraoperative and postoperative outcomes and mean maternal hospitalization times did not differ between groups. Neonatal lengths of hospitalization and neonatal intensive care unit admission rates did not differ between P1 and P2. Rates for cord blood pH of 7.1 or less were 10.7% and 5.3% in groups P1 and P2, respectively (P = 0.016). The respective rates for 5-minute Apgar scores of 7 or less were 5.8% and 2.3% (P = 0.031). The adverse composite neonatal outcome rates were 32.2% in P1 and 15.6% in P2 (P < 0.001). Worse neonatal outcome was dependent on time period (P1; odds ratio, 2.12; 95% confidence interval, 1.27–3.55; P = 0.004) and gestational age at delivery (odds ratio, 0.68; 95% confidence interval, 0.62–0.760; P < 0.001) but not on the decision-to-delivery interval.
The departmental protocol designed to shorten decision-to-delivery interval for ECS for NRFHR resulted in shorter decision-to-delivery intervals and better early neonatal outcomes, without increasing maternal complications. This program was created to improve communication skills among staff members and to perform simulation drills to assess and improve obstetric team performance. Monitoring delivery timing is essential to assess the quality of obstetrics units, and a management protocol to shorten the decision-to-delivery interval is achievable.
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv (E.W., J.B., N.F., A.B.-H., O.S., A.G., M.K.); Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon (E.W., J.B., N.F., O.S., A.G., M.K.); and Department of Obstetrics and Gynecology, Rabin Medical Center, Petah-Tikva (A.B.-H.), Israel