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Achievability of the 30-minute standard for urgent and emergent cesarean delivery: a systematic review
Abstract Number: S 37
Abstract Type: Meta Analysis/Review of the Literature
BACKGROUND: The American Congress of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynaecologists both support emergent cesarean delivery within 30 minutes. However, the ideal decision-to-delivery interval remains controversial as many institutions report difficulty in achieving this standard. The objective of this systematic review was to evaluate the feasibility and safety of emergency cesarean deliveries conducted within 30 minutes compared to deliveries conducted after 30 minutes.
METHODS: Electronic databases from inception to January 2013 were searched. Eligible studies reported decision-to-delivery or decision-to-incision intervals for non-elective cesarean deliveries. Both emergent and urgent deliveries (also known as category 1—maternal or fetal compromise with immediate threat to life, and category 2—maternal or fetal compromise with no immediate threat to life but requires expeditious delivery) were included. Two reviewers independently reviewed the identified studies for inclusion. The outcomes of interest included the feasibility and neonatal outcomes.
RESULTS: Out of 740 abstracts identified in the primary search, 32 studies (22,489 patients) met eligibility criteria. Data on the proportion of emergent and urgent deliveries accomplished within 30 minutes from decision-to-delivery was available in 23 studies (16,073 patients). Combined, only 30% of emergent and urgent deliveries were achieved within 30 minutes. However, when one large study of 9,122 patients was removed in a sensitivity analysis, the achievement rate was 50%. In 7 US studies (3,783 patients) where decision-to-incision was reported, 64% were achieved within 30 minutes. When analysis was limited to 2,310 “true” emergency (category 1) cases, 47% were achieved within 30 minutes. Included studies accomplished target intervals from 16-100% of the time, with median decision-to-delivery intervals from 10 to 48 minutes and median decision-to-incision intervals from 16 to 23 minutes. Neonatal outcomes were reported in 12 studies. The majority of studies reported improved neonatal outcomes when the delivery interval exceeded 30 minutes.
CONCLUSIONS: Delivery within 30-minutes was not achieved in a substantial proportion of cases. However, the significance of failing to accomplish this standard remains inconclusive as outcomes varied among the included studies. Future studies should investigate terminology and universal classifications of levels of urgency in obstetrics and should include full standardized reporting of neonatal outcomes which may generate higher quality evidence needed to guide clinical decisions.