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.