Emergency Caesarean Sections and Decision to Delivery Interval Jeremy Davies Brighton – 15th September 2009 Emergency Caesarean Sections and Decision to Delivery Interval

Aims Clarification of urgency/DDI Improving communication Improving performance

43 y.o. Ninth baby PMH – prev. LSCS, mod severe asthma; obese Resolving brady at 8 cm ARM/FSE/non-resolving brady Decision: LSCS Failed spinal -> GA Delivery (DDI 38’) Profoundly disabled child

DDI 38’ - Judgment Negligence upheld 2 min excess getting to AR 2 min excess getting to Theatre 9 min excess anaesthetic time [6 min for venflon dislodgement]

Hypoxic Ischaemic Encephalopathy 1% of all births 10% perinatal deaths Evidence pH<7.0; need for resuscitation Diagnosis/prognosis MRI Mild/moderate/severe

Decision-to-Delivery Interval (DDI) Traditional guideline = 30 minutes ‘Arbitrary time limit’ Is it deliverable? Oxford study: <50% under 30 minutes Patient needs to be in theatre within 10 mins

DDI – Rationale for 30 minutes ‘Arbitrary time limit’ Sometimes 30 mins is too long Severe brady+placental abruption: DDI 15min Severe brady> 20min: fetal asphyxia

DDI and National Sentinel CS Audit Association between DDI and fetal outcome Odds of 5 min Apgar scores <7 Babies c DDI <30 vs Babies 31-75 (OR 1.1 95% CI 0.9-1.4) Babies c DDI >75 mins: 80% higher chance of Apgar <7 NICE 2004

DDI and National Sentinel CS Audit (cont’d) ‘A DDI <30 min is not in itself critical in influencing baby outcome, but remains an audit standard for response to emergencies.’ The 75 minute DDI should be added as a clinically important audit standard and all deliveries by emergency caesarean should occur within this time’ (NICE 2004)

DDI and Anaesthetists Pressure to avoid GA DDI - GA vs RA DDI: GA 22 min; spinal 29 min; top-up 44 min ‘Time for surgical readiness’ - GA vs RA GA 15 min; spinal 28 min Levy – ‘all Category 1 sections require GA’

Categories of Caesarean Section Category 1 – Immediate threat to life of the woman or fetus Category 2 – Maternal or fetal compromise which is not life-threatening Category 3 – No maternal or fetal compromise, but early delivery necessary Category 4 – Delivery timed to suit woman or staff (elective) Lucas et al JRSM 2000

Development of the Categorisation system 6 Maternity units Potential options 1-5 scale VAS Time frame (max time to deliver) Clinical definition Anaesthetic technique

Scrutton/Kinsella modification 2009 Modified wording 349 maternity professionals ‘modification should not be adopted’

Scrutton/Kinsella 2 Category 1 examples Cat 1 – cord prolapse; major abruption; maternal cardiorespiratory distress Cat 2 – late decels; bleeding praevia without compromise; failed instrumental without compromise Cat 3 – deteriorating maternal medical condition 66% felt 30’ DDI should not apply to Cat 2

Labour Ward Management of Caesareans

National Guidance NICE CNST CESDI Royal colleges RCA – 85% Em LSCS under RA

Caesarean Section Clinical Guideline NICE 2004 ‘A DDI <30 min is not in itself critical in influencing baby outcome, but remains an audit standard for response to emergencies.’ The 75 minute DDI should be added as a clinically important audit standard and all deliveries by emergency caesarean should occur within this time’

CNST – NHSLA Standard 2 – Criterion 6 ‘There must be a classification for all caesarean sections as agreed by the maternity service and following the guidance of NICE’

RCOG Good Practice Statement Universal adoption of 4-point categorisation Effective communication between team members Need to define specific roles for team Drills to test transfer to theatre for cat 1 Individualise urgency assessment – continuous spectrum of risk

Communication and anticipation Attend Ward Round Ongoing communication re progress Good epidural maintenance

Specific concerns Difficult airway Obesity Poor English PET Low fetal reserve

Emergency LSCS Use 4-point categorisation Expedite to theatre ?2222 Use role definition

Is the insult reversible? Will the fetus respond to resuscitation? Yes Maybe No Supine hypotensive syndrome Cord prolapse Abruption Epidural dips Infection Rupture Hyperstimulation Placenta praevia

Fetal resuscitation S – Syntocinon off P – Position in Left lateral O – Oxygen I – iv fluids L – Low BP: ephedrine T - Tocolysis

Fetal monitoring CTG Doppler FSE

ANAESTHETIC PRACTICALITIES

Does Category 1 = GA? ‘All Category 1 sections should be GA’ D Levy Anaesthesia Anaesthetic decision Autonomous clinicians Risks unappreciated by others

Category 1 Immediate threat to life NICE, Scrutton/Kinsella examples

Maternal Category 1 Cardiorespiratory collapse eg total spinal Uncontrolled haemorrhage/hypovolaemia Major APH Placenta praevia; abruption Uterine rupture

Fetal Category 1 Non-resolving fetal bradycardia pH ???

High Risk GA Eg obese ++; known/predicted difficult airway Maternal Cat 1 GA attempted anyway Fetal Cat 1 – prioritise mother over fetus But severely handicapped child..... Obese + mallampati 3 ....

Category 2 Regional Mobilise as if for DDI <30 mins Respect obstetrician’s judgement re urgency Eg poor CTG + IUGR DDI must be <75 mins Monitor FHR

Epidural top-ups Careful maintenance during labour Lignocaine 2%+ epinephrine+ bicarb

Spinals Rapid sequence spinal Preoxygenate Someone else secures IV access Fentanyl

Audit of Emergency sections 2004 <50% of ‘emergency’ caesareans with DDI<30’ 2007 3 month audit – comprehensive Cat 1: n=5 mean DDI 16.2 mins (9-22) Cat 2: n=26 mean DDI 39.9 mins (30-54)

Summary Use and understand categorisation Develop rapid response systems appropriate to your labour ward Communicate, monitor, anticipate Mandatory GAs are rare Cat 2 DDI: aim for 30’; ok to take longer with some; all to be done by 75’ Monitor FHR in theatre

Summary so far ….. 30 min DDI = auditable standard Difficult Unjustified CNST obligation to expedite and communicate RCA pressure to keep GA rate low Pathological and legal distinction between acute and chronic deterioration

Fetal ASA F1 – Healthy F2 – Mild disease, no compromise F3 – Compromising fetal disease F4 – Fetal disease threatening life F5 – Moribund – already damaged F6 – Stillbirth

Fetal Stress Contractions interrupt gas exchange Prolonged contractions OR reduced reserve worsen gas exchange further IUGR Reduced retroplacental space reservoir (?=FRC) Reduced Wharton’s jelly

Non-reassuring/pathological CTGs = deteriorating fetal condition Spinal/epidural topup may be appropriate Combination of ominous features may constitute category I/GA

Question 1: Fetal Reserve Antenatal conditions IUGR; postmaturity; oligohydramnios Intrapartum conditions Maternal pyrexia; chorioamnionitis; meconium Fetal ASA

How common are category 1 sections? National Sentinel 16% of all CS 8% if supporting evidence Anaesthetic technique GA 35% Spinal 42% Top up 22%