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

A prospective cohort study was conducted from March to May 2018 among women who underwent category-1 emergency C/S at Gondar University Specialized Hospital obstetrics operation room, recovery room and wards located in Gondar town, Northwest Ethiopia.

A total of hundred and sixty-six clients were enrolled in the current study with a response rate of 98.2%and 3 of participants were excluded from the study because of incomplete data. Majority of participant’s 68 (41.7%) age was in the range of 25–29 years. Around 32(19.6%) of women had history previous C/S and almost a half of clients had college or university level of education. The mean weight, height and gestational age of participants were 66 ± 10 Kg, 1.61 ± 0.06 m and 38 ± 1 weeks, respectively. The majority of participants 85(52.1%) had BMI between 25 and 29.9 Kg/m².The mean weight of the new born was 3.04 ± 0.19 Kg (Table 1). Most of clients were operated under spinal anesthesia. Single attempt lumbar puncture was demonstrated in 54(33.15%) participants and two, three, and four or more attempts were noted in 68(41.75%), 23(14.1%), and 2(1.2%) participants respectively.

The mean ± SD preoperative systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, oxygen saturation, temperature and urine output were 125 ± 16 mmHg, 73.5 ± 10.9 mmHg, 97.8 ± 14.9 beats/minute, 20 ± 2.5 breaths/minute, 96 ± 2%, 36 ± 04°c and 55 ± 50.8 ml respectively. The mean ± SD post-operative systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, oxygen saturation, temperature and urine output were 106.5 ± 16.7 mmHg, 62.65 ± 9.96 mmHg, 90 ± 11.08 beats/minute, 19 ± 1.9 breaths/minute, 96.4 ± 1.9%, 35.9 ± 9.8 °C and 192 ± 95.8 ml respectively. None of the vital signs was associated with DDI or feto-maternal outcomes.

The leading indications for category-1 emergency C/S were fetal distress (52.15%), multiple previous C/S scars with ongoing labor (9.82%) and cephalopelvic disproportionate (9.20%). Others are prolapsed umbilical cord, placental abruption, failed instrumental delivery, imminent uterine rupture, placenta previa, severe pre-eclampsia and eclampsia (Fig. 1). Around 5.5% of clients had combination of indications.

The recommended decision to delivery time interval (DDI below 30 min) was achieved only in 32 (19.6%) of category-1 emergency C/S. The mean ± SD of DDI was 42 ± 21.4 min. The mean ± SD of time taken from decision of C/S to transfer to OT was 21.58 ± 19.76 min and from arrival at the operation theater to skin incision was 11.5 ± 3.6 min (Table 2).

Around 152 (93.3%) of clients had ANC follow up and out of those, 31 (20.4%) had DDI below 30 min. The majority of cases were operated by senior residents and out of those, 26 (20.8%) had DDI below 30 min. Most of clients 63 (82.9%) were anesthetized by BSc holder anesthetists and out of those, 13 (17.1%) had DDI below 30 min (Table 3).

Time elapsed to collect materials, time of decision of C/S, time taken from decision to the operation theater, time taken to deliver anesthesia and operation time were associated with prolonged DDI (Table 4).

Other factors such as unavailability of clinicians (anesthetists 8(4.9%), surgeons 3(1.8%), and midwifes 3(1.8%)), hesitation of the client to give consent 18(11%), unplanned conversion to general anesthesia 2(1.2%), lack of operation table 11(6.7%), difficulty of intravenous access 7(4.3%), waiting for CBC results 1(0.6%), waiting of senior surgeon 1(0.6%) and waiting for consultant anesthetist 1(0.6%) had no association with prolonged DDI .

A total of 163 deliveries were included in the study. Apgar score < 7 was recorded in 52 newborns at the 1st minute and in18 at the 5th minute. Bag and mask resuscitation was done in 45 newborns, 7 newborns were intubated, chest compression was done for 7 newborns and 17 were admitted to the neonatal intensive care unit and 4 newborns died (3 still birth and 1 after delivery) (Fig. 2). Among 131 newborns who delivered with a DDI longer than 30 min, 40 had Apgar score < 7 at the first minute, 13 had Apgar score < 7 at the 5^thminute, 38 had resuscitation via bag-mask ventilation, 5 had intubation, and 6 had chest compression (Table 5).

Out of 163 mothers who delivered with category-1 emergency C/S, 16 were transfused, 10 had developed fever, 4 had wound infection, 2 had hysterectomy, 8 had lost blood which was estimated to be more than 1000 ml and 1 had died (Fig. 3). Among 32 mothers whose DDI was longer than 30 min, 12 were transfused, 8 had developed fever, 2 had developed wound infection and 1 had hysterectomy (Table 6).

Decision to delivery time interval is a time range between decision for C/S and delivery of a newborn. This is the critical time interval that determines the feto-maternal outcome in category-1 emergency C/S [8]. The current study showed that only 19.6% of women who underwent category-1 emergency C/S were delivered within the recommended DDI of 30 min. The mean ± SD of DDI was 42 ± 21.4 min which is similar with a study done by Sunanda et al. in which the mean ± SD was 36.3 ± 17 min [21]. The difference might be due to sample size. Another study done in Oman concluded that a DDI below 30 min was achieved in 23.8% of category-1 emergency C/S [22] which is comparable with the current study. On the other hand, a study done in Benin teaching hospital has showed that a DDI below 30 min was achieved in only 5.7% of emergency C/S and the mean ± SD of DDI was 106.3 ± 79.5 min [23]. This finding is low in comparison with the current study.

In this study, time to collect surgical materials had a positive association with prolonged DDI in category-1 emergency C/S(AOR =, CI =, p=).This is consistent with a research done by Tak Yeung Leung et al. which has stated that a DDI below 30 min was achievable if the operation facilities were easily available [24]. Another study has showed that lack of surgical equipments was the main factor for prolonged DDI time [25]. A DDI below 30 min was difficult to attain in emergency C/S due to the infrastructural challenges [23].

In the current study, the mean time from decision to arrival to the operation theater was 21.58 ± 19.76 min. A research done by Wong et al. concluded that the major determinant for prolonged DDI was the time taken for transfer of clients to the OT [26]. Another study also has stated that preparation and transfer to the operation theater have significantly prolonged DDI with the average of 15.9 min [27].The mean time taken to deliver anesthesia after the clients were arrived at the operation theater was 11.5 ± 3.6 min. A study has showed that delays in the preparation and administration of anesthesia were significantly associated with prolongation of DDI [28].

Category-1 emergency C/S done in the night time had generally shorter DDI when it compared with the day time which was 18(29%) vs 14(13.9%). This result was comparable with the study done in Nysamba Hospital, Uganda which has stated that C/S done during the day time had prolonged DDI than those done in the night [28]. This can be explained by; during the day time the operating tables might be occupied by elective cases.

A retrospective cohort study done in the University of Benin teaching hospital has showed that the most frequent causes for delay in emergency C/S were anesthetists delay and busy OT [29]. This finding is against with the current study and might be explained by committed anesthetists and availability of free operation tables in our setup.

The indication for more than a half of the category-1 emergency C/S was fetal distress. This was comparable with a study done by Zwuditu et al. [30] Most of the indications were also consistent with that of a research done by Dr. Ban Leong et al. [13, 28]. A DDI below 30 min was best achieved when the indication was failed instrumental delivery. Fifty-seven percent of mothers with the indication of failed instrumental delivery have delivered within 30 min during C/S. This might be due to the locations the delivery rooms which are very near to the OT and make easy to transfer the mother to the OT immediately. In contrast, another study has showed that DDI below 30 min was achieved among women with the indication of non–reassuring fetal heart rate. The 3/4th of women with this indication has delivered within the recommended DDI [31].

The most of participants (90.2%) were operated under spinal anesthesia. This result was in accordance with a previous study in which 97.2% of category-1 emergency C/S were done under spinal anesthesia [23]. General anesthesia was administered in 16 clients and the attainments of DDI below 30 min was 37.5% [26]. A prospective study done by Mackenzie IZ et al. claimed that general anesthesia was significantly associated with shorter DDI than regional anesthesia for emergency caesarean section [32].

Most category-1 emergency C/S (76.7%) in our study was performed by senior residents (R3 and R4) and 23.3% by junior resident (R2). Achievement of DDI below 30 min was 20.8 vs 15.8% respectively. Senior obstetricians were not evolved in any of cases. However, the experience of obstetric residents was not a statistically significant determinant of DDI. This is supported by a prospective study done by Mackenzie IZ et al. which stated that the seniority of the surgeon didn’t influence the DDI [32]. In the majority of the cases (44.6%), anesthetic care was provided by BSc degree graduate anesthetists and the remaining 32.5 and 11.7% by MSc degree in anesthesia students and MSc graduates respectively. The study has denied that experience of the anesthetists had no association with DDI. In contrast to our finding, there is a study that showed lack of experience of the obstetricians, anesthetists and hesitation of the pregnant mother to give consent can be barriers to achieve shorter DDI [25].

In this study there was no association between DDI and feto-maternal outcome. Most of the literature stated that, there was no association between DDI and feto-maternal outcome during category-1 emergency C/S [13, 28, 31]. On the other hand Jane Thomas et al. stated that only delays in DDI longer than 75 min were significantly associated with worse feto-maternal outcome in category-1 emergency C/S [33]. Despite these, another study has showed that during life threatening conditions, quicker delivery can result in better feto-maternal outcomes [24].

Many newborns with adverse outcome had DDI longer than 30 min but it was not statistically significant. This result is supported by previous studies that claimed longer DDI was not significantly associated with worse neonatal outcome [27, 34]. In contrast, another study has stated that there was significant improvement in feto-maternal outcome when DDI was below 20 min [35].

Among newborns who were delivered with DDI longer than 30 min, 40 had Apgar score < 7 at the 1^stminute, 13 had Apgar score < 7 at the 5thminute, 38 had resuscitation via bag-mask ventilation, 5 had intubation, 6 had chest compression, 3 had NICU admission and 3 had died. On the other hand, when DDI was below 30 min, 12 had Apgar score < 7 at 1stminute, 5 had Apgar score < 7 at fifth 5th minute, 7 had resuscitation via bag-mask ventilation, 2 had intubation, 2 had chest compression, 2 had NICU admission and 1 had died.

Among 131 mothers who delivered with DDI longer than 30 min, 12 had blood transfusion, 8 had developed fever, 2 had developed wound infections, 1 had hysterectomy and 7 had lost blood which was estimated to be more than 1000 ml. On the other hand, among 32 women who delivered with DDI below 30 min, 4 had blood transfusion, 2 had developed fever, 2 had developed wound infections, 1 had hysterectomy, and 1 had lost blood which was estimated to be more than 1000 ml. Despite our findings, a prospective study has showed that around 27% of women had one or more complications during caesarean section in which category-1 emergency C/S delivery significantly associated with these complications [36].

We strongly recommend that materials which are important for emergency C/S should be readily available in the supply room and obstetric pharmacy, anesthetic and surgical care for all category-1 emergency C/S should be provided by senior anesthetists, residents and consultants. Time of preparation and transfer to the OT should be reduced. It would be better if further study is done by incorporating late feto-maternal outcomes with larger sample size.

The strengths of this study is that subjects were homogeneous (category-1 emergency C/S) which could provide representative data and since it was prospective study which could make it appropriate to identify factors.

This study has not evaluated late feto-maternal outcomes, immediate fetal outcome was assessed only with the Apgar score due to the unavailability of umbilical cord blood рН analysis in the hospital and even if larger sample size is needed, due to short study period we included only 163 samples and might reduce the power of the study. These are limitations of the study.