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EVALUATION OF 'DECISION TO DELIVERY INTERVAL' AND CAUSES OF DELAY IN EMERGENCY CAESAREAN SECTIONS IN A TERTIARY CARE HOSPITAL.

Byline: Simi Fayyaz, Sonia Rafiq and Shehzadi Saima Hussain

Abstract

Objective: To evaluate decision to delivery interval in emergency caesarean sections performed in tertiary care hospital and to evaluate the factors causing delay.

Methodology: This cross sectional observational study was conducted in Department of Obstetrics and Gynaecology, B unit, Lady Reading Hospital from 1st march 2014 till 31st august 2014. All emergency caesarean section category A (requiring delivery within 30 min from decision to delivery ) were included and time taken from decision to delivery was noted, in cases where there was delay, the reason was highlighted. Elective caesarean sections and those not requiring urgent caesarean sections were excluded from study. Descriptive statistics were used to analyze the data and results were expressed in percentages.

Results: Total 102 patients were enrolled in this study, in 35.96% (n=41) there was no delay , in 21.05% (n=24) delay was due to non availability of operating table (it was already occupied), delay in arrangement of medicine led to delay in 13.15% (n=15) patients, non-availability of basic investigation (blood group, HBS/HCV) were responsible for delay in 10.52% (n=12) of cases, cross matched blood arrangement was delaying factor in 7% (n=8) of patients, in 1.75% (n=2) of patients delaying in shifting was found .Regarding indications for caesarian section, the commonest indication was fetal distress (n=25, 24.5%) followed by obstructed labour (n=21, 20.5%).

Conclusion: caesarean section within 30 minutes is possible, ensuring medicine availability and increasing the number of operating tables available for surgery will lead to drastic improvement in achieving our goal.

Key Words: Decisiondelivery interval, Emergency cesarean delivery

INTRODUCTION

National Confidential Enquiry into Patient Outcome and Death (NCEPOD), recommends a four-step classification for the urgency of caesarean sections. In this scheme, grade 1 is caesarean in case of immediate threat to woman or fetus life; grade 2 maternal or fetal compromise but no immediate life threat grade; 3 early deliveries required without any threat to life; and grade 4 elective cesarean sections1. In the instances of suspected or confirmed acute fetal compromise, baby should be delivered within 30 minutes2. Thus the clinicians delivering babies in an emergency are faced with an onerous responsibility2,3. Decision to delivery interval (DDI) is defined as the interval in minutes from the date and time of decision to carry out caesarian section to the date and time of delivery of baby4. This is an uphill task to achieve in our set up.

The major hurdles in this 30 minutes' target of DDI are, increase in patients load which can lead to a long waiting list for surgery; problems in availability of enough number of operation theatres; scarcity of surgical staff in emergency hours including surgeons, anaesthetists, nurses and theatre staff; lack of coordination at all levels; and transportation delay in shifting the patients from labour rooms to operation theatre2. Identifying these factors responsible for delay in decision to incision time, would also enable us in setting standards and clinical guidelines to provide optimal care to the patients.

METHODOLOGY

This cross sectional observational study was conducted in Department of Obstetrics and Gynaecology, B unit, Lady Reading Hospital from 1st march 2014 till 31st august 2014. All emergency caesarean section category A (requiring delivery within 30 min from decision to delivery) were included and time taken from decision to delivery was noted. An interval of more than 15 minutes at any step was considered as delay although the optimal decision to delivery interval is 30 min especially for category I cases. Cause and reason of delay were noted. Elective caesarean sections and those not requiring urgent caesarean sections were excluded from study. Descriptive statistics were used to analyze the data and results were expressed in percentages.

RESULTS

A total 102 patients were enrolled in this study, no stillbirths or maternal deaths were recorded in this study. Table 1 shows causes of delay. In 35.96% (n=41) there was no delay, in 21.05% (n=24) delay was due to non availability of operating table ( it was already occupied) , delay in arrangement of medicine led to delay in 13.15% (n=15) patients, non-availability of basic investigation (blood group, HBS/HCV) were responsible for delay in 10.52% (n=12) of cases, delay in cross matched blood arrangement was delaying factor in 7% (n=8) of patients, in 1.75% (n=2) of patients delaying in shifting was found. Regarding indications for caesarian section, the commonest indication was fetal distress (24.5%) followed by obstructed labour (20.5%). Other indications are depicted in table 2.

DISCUSSION

The aim of this study was to assess the decision to delivery interval (DDI) and evaluate the causes of delay in emergency caesarean sections. DDI of 27.4 minutes for crash caesareans (impending fetal death), 42.9 minutes for fetal distress and 71.1 minutes for cases without fetal distress was reported by Mackenzie et al9. In our study the DDI was 28min in which no delay was found, matching with this study. Kolas et al and Sayegh et al in separate studies reported mean DDI of 39.5 minutes and 52.4 minutes. The result of our study is an improvement from results obtained in similar studies from Nigeria4 where only 5.7% of emergency CS were performed with no delay. A study by Gita Radhakrishnan et al2 had DDI of 122min for category 1 caesarian sections which is in contrast to standard time and in only 1.8 % cases DDI of 30 minutes or less was achieved.

Sayegh et al11 observed delay due to non availability of operation theatres and that the maximum delay occurred in shifting of patients to the operation theatre. In our study major causes of delay were non availability of operating tables which is accepted as described in other

Table 1: Causes of delay and DDI

S. No Causes of delay###Number of cases###Percentage###DDI(minutes)

1###No delay###N=41###35.96###28min

2###Non availability of operating table###N=24###21.05###70min

3###Delay in arrangement of medicine###N=15###13.15###102min

4###Non availability of basic investiga-

###N=12###10.52###50min

###tions(blood group, hepatitis profile)

5###Delay in cross matched blood###N=08###7###45min

6###Delay in shifting patient to operation

###N=02###1.75###60min

###theatre

###Total###102###100

Table 2: Indications of caesarian section

S. No###Indications###Number of c/section###Percentage

1###Fetal distress###25###24.5

2###Obstructed labour###21###20.5

3###Footling breech in labour###06###5.8

4###Placental abruption###10###9.8

5###Placenta previa###8###7.8

6###Cephalopelvic disproportion in labour###08###7.8

7###Previous 2 or more c/section###12###11.7

8###Cord prolapsed###12###11.7

studies from Nigeria in which 80% of the delay was due to busy theatre suits and responsible for longest delay i.e. 70min mean DDI. Another study also showed that 66% patients got delayed due non availability of operation theatres2.

Time taken in arranging blood for the patients is a factor causing delay in shifting the patient to OT besides non availability of OT5.

CONCLUSION

Caesarean section within 30 minutes is possible, ensuring medicine availability and increasing the number of operating tables available for surgery will lead to drastic improvement in achieving our goal. This evidence would also enable us in setting standards and clinical guidelines in order to provide good care to our patients. This study can serve as preliminary study to be followed by other large scale studies which can provide the required data to health care authorities for planning appropriate strategies.

REFERENCES

1. Cerbinskaite A, Malone S, McDermott J, Loughney AD. Emergency caesarean section: influences on the decision-to-delivery interval. J Pregnancy. 2011;2011:640379.

2. Radhakrishanan G, Yadav G, Vaid NB, Ali H. Factors affecting "decision to delivery interval" in emergency ceasarian sections in a tertiary care hospital: a cross sectional observational study. Int J Reprod Contracept Obstet Gynecol 2013; 2:651-6

3. Sikandar R, Nisar N, Naz F. Intrapartum stillbirths: is there a scope to improve. J Soci Obstet Gynae Pak 2013; 3:165-9.

4. Chukwudi OE, Okonkwo CA. Decision-delivery internal and perinatal outcome of emergency ceasarian sections at tertiary institution. Pak J Med Sci 2014; 30:946-50.

5. Shah N, Hossain N, Shoaib R, Hussain A, Gillani R, Khan NH. Socio economic Characteristics and the three Delays of Maternal Mortality. J Coll Physicians Surg Pak 2009; 19:95-8.

6. Korda V, Zimmermann R. Five-year impact of a new departmental protocol on emergency cesarean target times. Open J Obstet Gynecol 2013; 3:148-53.

7. Leung TY, Chung PW, Rogers MS, Sahota DS, Lao TT, Hung Chung TK. Urgent cesarean delivery for fetal bradycardia. Obstet Anaes Digest 2011; 31:39.

8. Kolas T, Hofoss D, Oian P. Predictions for the decision to delivery interval for emergency Cesarean section in Norway. Acta Obstet Gynecol Scand 2006; 85:561-6.

9. Mackenzie IZ, Cooke I. What is a reasonable time from decision-to-delivery by caesarean section Evidence from 415 deliveries. Br J Obstet Gynaecol 2002; 109:498-504.

10. Fyneface-Ogan S, Mato CN, Enyindah CE. Decision to delivery Interval: Reasons for delay. J Med Biomed Res 2009; 8:72-8.

11. Sayegh I, Dupuis O, Clement HJ, Rudigoz RC. Evaluating the decision to delivery in emergency caesarean sections. Euro J Obstet Gynaecol Reprod Biol 2004; 116:28-33.

12. Singh R, Deo S, Pradeep Y. The decision-to-delivery interval in emergency Caesarean sections and its correlation with perinatal outcome: evidence from 204 deliveries in a developing country. Trop Doct 2012; 42:67-9.
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Publication:Journal of Postgraduate Medical Institute
Article Type:Report
Date:Dec 31, 2015
Words:1743
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