1. Royal College of Obstetricians and Gynaecologists Setting standards to improve women’s health Risk Management and Medico-Legal Issues In Women’s Health Joint RCOG/ENTER Meeting Please turn off all mobile phones and pagers

2. Audit of decision to delivery interval for emergency caesarean sections in 2007 Michelle Judd Consultant Obstetrician

4. rural location Bury St Edmunds market town 2500 deliveries per year 25% CS rate

5. Aims and objectives To ensure that the urgency of an emergency CS is documented in a standardised way To use timing standards which have been agreed between obstetric and anaesthetic staff To review decision to delivery interval for all emergency CS Required audit for the unit’s CNST Level 3 assessment

6. Audit standards CS grade IndicationDecision to delivery interval (minutes) 1Immediate threat to life of woman or fetus 30 2Maternal or fetal compromise, not immediately life threatening 60 3Needing early delivery but no maternal or fetal compromise To be delivered within an acceptable time 4Elective casesBooked on elective CS lists

7. Audit method Review decision to delivery interval for all emergency CS Data collected monthly using emergency CS diary Diary recorded –Reason for CS –Grade of CS –Decision time for CS –Time of delivery Results presented at monthly Clinical Governance meetings

8. Emergency CS decision to delivery interval % standard achieved in 2007

9. Audit results -Standards achieved for 2007 Grade 1 CS – target achieved 98% Grade 2 CS – target achieved 78% Grade 3 CS – target achieved 100%

10. Results: reason for delay Reason for delayNo.% Anaesthetic difficulty1224 Surgical difficulty36 Delay in transfer to theatre1528 Another obstetric case in theatre1224 Lack of staff/awaiting arrival staff611 Patient needed time to make decision24 Unknown (notes missing)12

11. Results: length of delay Delay (min) Anaesthetic problem Delay in transfer to theatre Other obstetric case in theatre Other causes 1-1041146 11-2052-2 21-302-12 >30<602231 >60--4-

12. Results: length of delay Delay (minutes)Number% 1-102549 11-20918 21-30510 >30<60816 >6047

13. Summary of delays Anaesthetic difficulties –Unavoidable delay –Most related to maternal obesity –Use of regional anaesthesia is safest option Delay in transfer to theatre –Avoidable delay –CDS Coordinator to be responsible for timely transfer to theatre Lack of obstetric theatre –Avoidable delay –Feasibility of providing another theatre when there is a second obstetric emergency

14. BMI at booking appointment BMIMidwifery-led careConsultant-led care 18.5-24.956%40% 25-29.930%20% 30-34.97%20% 35 or greater-10% Not recorded7%10%

15. Summary of delays Anaesthetic difficulties –Unavoidable delay –Most related to maternal obesity –Use of regional anaesthesia is safest option Delay in transfer to theatre –Avoidable delay –CDS Coordinator to be responsible for timely transfer to theatre Lack of obstetric theatre –Avoidable delay –Feasibility of providing another theatre when there is a second obstetric emergency

16. ….and finally Level 1 CNST in March 2004 Level 2 CNST in March 2006 Level 3 CNST in January 2008

18. Royal College of Obstetricians and Gynaecologists Setting standards to improve women’s health Risk Management and Medico-Legal Issues In Women’s Health Joint RCOG/ENTER Meeting Please turn off all mobile phones and pagers