Introduction
The American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetrics and Gynecology (RCOG) suggest that the time from decision of emergency cesarean section to the birth of the baby (Decision-to-delivery interval, DDI) should be within 30 minutes.1,2 However, in actual clinical practice, achieving the 30-minute goal is challenging in many settings from many reasons.3-5 In addition, there is no firm evidence to confirm that DDI within 30 minutes improve maternal and neonatal outcomes.6-8 However, it is recommended that cesarean section should be carried out within 30 minutes when there is immediate threat to life of the woman or fetus, and within 75 minutes for those with maternal or fetal compromise that is not immediately life-threatening. The 30- and 75-minute goals are also recommended for measuring the performance of an obstetric unit. 9
In developed countries, achievement of 30-minute goal for emergency cesarean deliveries was approximately 40%–65%.4,5,10 On the other hand, the achievement has been reported to be lower than 20% in developing countries.11-13 In order to achieve the 30-minute goal, there are many challenges that may be related to logistics, patients, anesthetic, obstetric condition, communication and teamwork, depending on the context of each setting. 14,15 In general, care improvement process and better preparedness can possibly reduce DDI, such as re-locating operating and delivery rooms, availability of staff team, and effective communication and teamwork. 16
A previous study in Siriraj Hospital showed that only 3.5% of women underwent emergency cesarean section had DDI ≤30 minutes, while 52.0% had DDI >75 minutes. 17 Another study in women with non-reassuring FHR also showed that only 6.6% achieved the 30-minute goal. 18 Better performance was reported in women with abnormal FHR in NICHD category III and during after office hours.
Accordingly, a multidisciplinary team, including, obstetricians, anesthesiologist, pediatricians, and other related personnel, has developed a care process improvement protocol called “code blue” in order to shorten the DDI for emergency cesarean section. The protocol includes improvement in various process including decision for cesarean section, team communication, patient preparation and transfer, and team preparedness and readiness. Conditions for emergency cesarean section have been clearly defined, which are abnormal FHR in NICHD Category III, hypovolemic shock, amniotic fluid embolism, cord prolapsed, and uterine rupture. Awareness has been raised among all staff members regarding the importance of the 30-minute goal. Communication with the staff and operating room team is initiated immediately at the time of decision together with patient preparation. Transfer process is also facilitated. During after office hours, when necessary, an extra operating room and nurse team will be made available. The “code blue” protocol has been approved and implemented in 2017 and the new workflow and instructions were explained and distributed to every staff and related personnel in the Department.
However, there has been no concrete evaluation of improvement in DDI after the implementation of ”code blue” protocol. Therefore, this study was conducted to compare the DDI and other time intervals for emergency cesarean section before and after the “code blue” protocol implementation. Factors associated with delayed time intervals and pregnancy outcomes were also evaluated.