Rationale, aims and objectives: In emergency cesarean section, time from decision to delivery should be within 30 minutes. This study aims to compare decision-to-delivery interval (DDI) in emergency cesarean section before and after the implementation of a specific care process improvement protocol (“code blue”). Methods: 300 women underwent emergency cesarean section were included. Study and comparison group were 150 women before and 150 women after “code blue” protocol implementation. Medical records were reviewed for clinical information. Timing of decision-to-delivery process was compared. Results: Maternal age, parity, and GA at delivery were comparable between the 2 groups. The most common indication was abnormal FHR in NICHD category III in both groups. Median DDI was significantly shorter in study than comparison group (22 vs. 52.5 minutes, p<0.001). In addition, median decision-to-room and decision-to incision intervals were also significantly shorter (8 vs. 25 minutes and 18 vs. 45 minutes, p<0.001, respectively). Women in study group had significantly higher rate of DDI ≤30 minutes than in comparison group (80% vs. 8%, p<0.001). Similar significant differences of each time interval and rate of DDI ≤30 minutes between the 2 groups were observed regardless of decision time. Only 5 (3.3%) of women in study group had DDI >75 minutes compared to 13 cases (25%) in comparison group (p<0.001). Pregnancy and neonatal outcomes were comparable between the 2 groups. Conclusion: The implementation of “code blue” protocol for emergency cesarean section results in significantly shorter DDI and other time intervals.