Abstract:
Background: Emergency cesarean delivery is done for optimal outcome when vaginal delivery poses a threat to either the mother, fetus or both. American and European obstetric guidelines recommend that, for fetal compromise in labor, delivery should be accomplished ideally in 30 minutes to minimize negative fetal effects of intrapartum hypoxia which complicates about 1% of labors and results in death in about 0.5 in 1000 pregnancies and cerebral palsy in 1 in 1000 pregnancies. The dilemma is that if intervention leads to a good outcome it may be viewed as unnecessary whereas if it leads to a bad outcome it may be interpreted as too slow or too late.
Objective: To determine the decision to delivery interval and its associated feto-maternal outcomes within 24 hours post-operation at Moi Teaching and Referral Hospital (MTRH).
Methods: This study was conducted in MTRH's Riley's Mother and Baby Hospital (RMBH), a specialized maternity wing with a 17-bed labor ward, a 30-bed antenatal ward and a 35-bed postnatal ward. This was a cross sectional study involving examination of 196 women who underwent emergency CS at RMBH. Relevant data was collected in a structured data collection form, from decision to perform CS to 24 hours following CS, entered into a computer access database and analyzed using statistical computation R. Descriptive data was summarized using measures of central tendencies (median, frequencies). Inferential statistics was presented using odd ratios and tabulated (p-value set at 0.05). The test for association between categorical variables was done using Pearson's Chi Square test while the test for association between categorical and continuous variables was done using the two sample Wilcoxon rank sum test. Data was presented in form of tables and graphs. Findings will be disseminated by publishing in reputable journal and presenting in scientific seminars.
Results: Fetal distress, labor dystocia and malpresentation were the leading indications for category I and II CS at 66.4%. Category I constituted 73 (37.2%) cases while category II constituted 123 (62.8%) cases. The median DDI was 114.0 (IQR: 77.8, 163.5) minutes with a minimum and maximum of 30.0 and 588.0 minutes, respectively. The median duration of decision-theatre time was 67 (IQR: 44, 116.5) minutes, theatre-induction time was 30 ( 20, 38) minutes, induction-skinincision time was 2.0 (IQR: 1, 3) minutes and skin incision-delivery was 4.0 ( IQR: 3, 6) minutes. One (0.5%) CS occurred within 30 minutes, 98 (50%) were accomplished within 120 minutes while 19 (20%) remained undelivered beyond 175 minutes of decision. Fetal outcomes (Admission to newborn unit, neonatal death or fresh stillbirths) had no association with DDI (p=0.35). There was no association between maternal outcomes (PPH, visceral injury, urinary bladder injuries, Sub Total Hysterectomy, uterine rupture, uterine dehiscence, thromboembolism) and DDI (p=0.35).
Conclusion: The median DDI was 114 mins and this is higher compared to AGOG recommendations of 30 minutes. The longest delay was observed between decision-theatre. There was no association between maternal outcomes and DDI (p>0.05). Majority of the infants with good APGAR score were delivered within a shorter DDI. The longest delay was contributed by the delay from decision making to receiving the patient in theatre.
Recommendation: Effort should be made to reduce the time from decision to induction of anesthesia. A study to establish factors influencing decision to delivery intervals is called for.