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Decision-to-Incision Time and Neonatal Outcomes: A Systematic Review and Meta-analysis

Tolcher, Mary C. MD; Johnson, Rebecca L. MD; El-Nashar, Sherif A. MBBCh; West, Colin P. MD, PhD

doi: 10.1097/AOG.0000000000000132
Contents: Labor Management: Review

OBJECTIVE: To systematically review the literature on the proportion of emergent cesarean deliveries accomplished within 30 minutes, the mean time from decision-to-incision or delivery, and differences in neonatal outcomes in deliveries accomplished within 30 minutes compared to beyond 30 minutes.

DATA SOURCES: Electronic databases (Ovid MEDLINE and EMBASE and were searched from inception to January 2013.

METHODS OF STUDY SELECTION: Eligible studies reported decision-to-incision time or delivery time intervals for nonelective cesarean deliveries. Both emergent and urgent deliveries (also known as category 1 and category 2 deliveries) were included. Two reviewers independently identified studies for inclusion.

TABULATION, INTEGRATION, AND RESULTS: Out of 737 reports identified in the primary search, 34 studies (22,936 women) met eligibility criteria. Seventy-nine percent (95% confidence interval [CI] 61–97%) of category 1 deliveries and 36% (95% CI 24–48%) of category 2 deliveries were achieved within 30 minutes, with significantly shorter time in category 1 compared to category 2 deliveries (21.2 compared with 42.6 minutes; P<.001). In the 13 studies that included neonatal outcomes, there was a higher risk of overall 5-minute Apgar score less than 7 (odds ratio [OR] 3.10; 95% CI 1.93–4.96) and umbilical artery pH level less than 7.10 (OR 3.40; 95% CI 2.38–4.87) in cases involving shorter delivery intervals. However, analyses limited to category 1 deliveries did not show a statistically greater risk of Apgar score less than 7 (OR 0.69; 95% CI 0.11–4.51) or umbilical artery pH level less than 7.10 (OR 1.10; 95% CI 0.28–4.40) with shorter delivery intervals. There was no difference by delivery interval in admission to neonatal intensive care units or special newborn units (OR 1.23; 95% CI 0.90–1.68).

CONCLUSION: Delivery within 30 minutes was not achieved in a substantial proportion of cases. The clinical significance of failing to achieve this standard remains uncertain.

Delivery within 30 minutes is not achieved in a substantial proportion of urgent and emergent deliveries; the clinical significance of this delay remains unclear.Supplemental Digital Content is Available in the Text.

Departments of Obstetrics and Gynecology, Anesthesiology, Medicine, and Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

Corresponding author: Mary C. Tolcher, MD, Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail:

The authors thank Ms. Patricia J. Erwin, Mayo Clinic Reference Librarian, for her help in the systematic search process, and Drs. M. Hassan Murad and Victor M. Montori at the Mayo Clinic for the methodology and statistical support.

Financial Disclosure The authors did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.