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Caesarean section (CS) is the most common surgery performed in obstetrics.[1] Even though CS can be a lifesaving procedure, it is a major surgery and is associated with maternal and neonatal risks, espe-cially in settings that have limited resources.[1,2]

One of the most important factors in performing a CS is the indication. When an emergency CS is indicated, the Royal College of Obstetricians and Gynaecologists (RCOG) and American Academy of Pediatrics (AAP) recom-mend a decision-to-delivery interval (DDI) of thirty minutes or less for all emergency CSs to minimalize neonatal hypoxic morbidity and mortality.[3-5] The thirty-minutes recommendation was agreed upon by a consensus of experts without any hard evidence.[6] Furthermore, due to weak health sys-tems, limited resources and insufficient personnel in low- and middle-income countries, the DDI is often pro-longed without any significant morbidi-ties.[7,8] Recent research has shown that if the DDI crosses the 75 minutes mark instead of the 30 minutes, the risk of significant maternal and neonatal mor-bidities increases.[9] When evaluating the optimal DDI, it is important to consider the degree of urgency of the CS. This classification is shown in Table 1 and is used worldwide.[10] With this knowledge, the RCOG is considering adjusting the recommendation for the DDI of a category 2 CS to 75 minutes instead of 30 minutes, while taking into account the maternal and foetal condition.[11]

Several factors have been described that influence the DDI, including location of the operation theatre and obstetric unit, availability of the operation theatre and team members, and the awareness of the urgency by the whole team.[6]

Cs trends and practices in ghana

Ghana’s latest health survey has shown that 13% of live births are delivered via CS.[12] This rate varies among the dif-ferent regions in Ghana.[3,12] Especially in urban areas, this rate was higher.[3,4]

In Holy Family Hospital (HFH), neonatal asphyxia after an emergency CS is one of the most common causes of neonatal morbidity and mortality. HFH is a district hospital located in Berekum, a city with 60,000 people in the western part of Ghana. Due to the lack of efficient treatment options, such as post- asphyxia neonatal cooling and a continuous positive airway pressure (CPAP) machine, the treatment of this condition in the hospital is limited. Therefore, one of the most important determinants to improve here is preven-tion. Research shows that DDI is one of the more essential variables in the pre-vention of neonatal asphyxia.[8,9] There is no data available on DDI in this par-ticular hospital, and Ghanaian national guidelines do not refer to RCOG and AAP recommendations. The aim of this study is to determine the mean DDI and to analyse the possible reasons for delay.

Methods

A prospective cross-sectional study was performed over one month from 12 February 2021 to 12 March 2021 in HFH in Berekum, a general hos-pital with an average annual num-ber of deliveries of around 3,500.

The hospital has an obstetric depart-ment located next to the opera-tion theatre. During duty hours, a house officer and medical officer are responsible for the entire hospital. The operation room nurses are pres-ent at the operation theatre, and the nurse anaesthetist has to be called.

All emergency CSs with complete records were included. Emergency CSs were defined as CS after failed assisted vaginal delivery, cord prolapse, placental abruption, ante partum haemorrhage, pathological cardiotocography (CTG)/ foetal distress, breech presentation in labour with contraindication for vaginal delivery and severe pre-eclamp-sia. Failed induction was excluded if no foetal distress was present.

DDI was defined as the time interval between the decision to perform a CS to the time of the actual delivery of the baby. The DDI was recorded in minutes.

A questionnaire was filled in by the doctor making the decision to perform the CS. The information recorded on these forms include: indication for the CS, estimation of gestational age, the time when the doctor was informed by the midwife to evaluate the patient, time of decision for CS, the time of incision, the time of delivery and, if applicable, the reason for delay. Along with this, information on the neonate was reported as the Apgar score at one min-ute and five minutes, weight and sex.

After collecting the data, the indica-tions for CS were categorised by urgency classification. Category 1 indications are cord prolapse, placental abruption and failed assisted vaginal delivery. Pathological CTG/foetal distress, breech presentation in labour and severe pre-eclampsia were classified as category 2. Category 3 included uterine inertia and cephalic pelvic disproportion.

A low Apgar score was defined as an Apgar score of 7 or lower at five minutes.

Results

During the one-month study period, 213 live birth deliveries were performed of which 60 were CSs; 45 of these CSs were emergency CSs. That gives a CS rate of 28% and an emergency CS rate of 75%. The questionnaires were filled out in 41 of the 45 cases. The indications for the emergency CSs are shown in Table 2. A DDI of less than 30 minutes was achieved in 17% of the cases. The mean DDI was 54 minutes.

Subgroup analyses

Subgroup analyses showed six emer-gency CSs with a category 1 indica-tion; the mean DDI in this group was 34 minutes. Category 2 included 28 emergency CSs, with a mean DDI of 60 minutes. The mean DDI was 53 minutes in the eight CSs in category 3. There was no difference seen in the DDI during the day and between different duty hours in the evening and night.

For cases with neonates born with a low Apgar score, the mean DDI was 95 minutes. This was seen in total in four cases, both in category 1 and 2 emergency CSs. One neonate died, born at a gestational age of thirty weeks with a birthweight of only I kilogram. The mother suffered from severe pre-eclampsia. The reasons for delay are laid out in Table 3. The most common reason was a long duration in the preparation of the patient and transport to theatre.

Discussion

The decision-to-delivery interval (DDI) in emergency caesarean sections (CSs) is considered an important determinant of perinatal outcome and has become a measure in audits of standard care.[13] This study evaluated the mean DDI in Holy Family Hospital Berekum. As is stated in the results, only 17% of the emergency CSs met the thirty-minutes rule. This is comparable to other low-resource settings.[8] However, the numbers are more promising if the research on aiming for a DDI of less than 30 minutes for category I and less than 75 minutes for category 2, as mentioned in the introduction, is taken into account. The results show a mean DDI in category 1 CS of 34 minutes, which nearly meets the 30-minute rule and a mean DDI of 60 minutes in category 2. However, due to the low number of cases of category 1 CSs, it is difficult to draw major conclusions here.

Preparation of the patient and transport to the operation theatre are reported as the main reasons for delay. Multiple pro-ceedings are necessary to perform a CS, including obtaining informed consent, determining blood group and haemoglo-bin level, and preparing pass iv-line and urine catheter. Further research should be done to determine possible opportu-nities to improve this process.

The second most reported reason of delay was that the doctor was too busy; this reason was only reported during duty hours. However, this didn’t result in a difference in the mean DDI. The doctor on call is responsible for the entire hospital, including a crowded emergency unit during duty hours, so constant avail-ability cannot be guaranteed. An additional obstetric or Emergency Room doctor during duty hours is needed to assure continuous care. Additionally, to improve the DDI, it is important that the process of emergency caesarean delivery is well known in the whole team.[6] Regular multidisciplinary team trainings and audits have been shown to be effective in reducing the DDI.[14] Regular audits are in place at HFH for the obstetric team as well as the neonatal team. However, a multi-disciplinary team training specifically focusing on the process of an emer-gency CS is lacking. Such a training can improve the communication skills and can increase the awareness of the importance of DDI in the whole team.[14]

Prioritisation by the doctor in the urgency of different indications to do a CS should also be considered.[15] At HFH, this prioritisation is not standard and only done arbitrarily. An effective way to improve the DDI in the cases that need it the most is to use the classifica-tion of urgency in the communication to the team. This can increase team readiness and motivation and makes the communication easy and clear.[15]

A main limitation of this study was its duration, resulting in a limited sample size. Especially in the subgroup analyses, this resulted in insufficient numbers to detect significant outcomes. In addition, there might be a recall bias. The doctor who performed the CS was asked to fill out the question-naire immediately. However, it is likely, due to busy hours, that this was not always achieved and that doctors filled out the questionnaires hours later.

Conclusion

In conclusion, this study has shown that a DDI of 30 minutes was only achieved in 17% of the cases. Nonetheless, in the most urgent cases, the category I CS, a mean DDI of 30 minutes was nearly achieved. The preparation of the patient and transport to the operation theatre are the main reasons for delay and provide the best opportunities for improvement. Therefore, in addition to the recommendations below, we recom-mend conducting a larger prospective intervention study to assess (potentially) effective interventions, such as reducing the time to prepare the patient for CS and transport to the operation theatre.

Recommendations

  • Implement regular multidisciplinary team training to improve communication and awareness
  • Implement the use of urgency caesarean classification to improve communication
  • Perform a prospective intervention study to improve preparation of the patient and transport to operation theatre

References

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