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

2. Aims Clarification of urgency/DDI Improving communication
Improving performance

3. 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

4. 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]

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

6. 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

7. 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

8. 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 (OR % CI )
Babies c DDI >75 mins: 80% higher chance of Apgar <7
NICE 2004

9. 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)

10. 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’

11. 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

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

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

14. 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

15. Labour Ward Management of Caesareans

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

17. 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’

18. 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’

19. 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

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

21. Specific concerns Difficult airway Obesity Poor English PET
Low fetal reserve

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

24. 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

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

26. Fetal monitoring
CTG
Doppler
FSE

27. ANAESTHETIC PRACTICALITIES

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

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

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

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

32. 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

33. 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

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

35. Spinals Rapid sequence spinal Preoxygenate
Someone else secures IV access
Fentanyl

36. 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)

37. 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

39. 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

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

42. 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

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

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

46. 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%