Safe timing for an urgent Caesarean section: what is the evidence to guide policy?

Abstract

Objective. To determine, from the evidence, what is the optimum decision to delivery (DDI) intervals in emergency Caesarean sections (CS). The aim of the study was to help guide policy in maternity services and identify issues relating to DDI and safe practice in maternity care. Method. A systematic review of the literature was undertaken. Assessment of the quality of eligible papers was undertaken using the Critical Appraisal Skills Program (CASP) rating. Results. There is no strong evidence that a DDI of 30 min or less is associated with improved outcomes for babies or mothers. Some evidence suggests that a DDI of greater than 30 min but less than 75 min confers benefit, but these findings were confounded by the indications for the emergency CS. Conclusion. Urgent CS should occur as soon as possible, but there is insufficient evidence to support a definite time frame, such as 30 min. A consistency of approach and nomenclature in describing the urgency of CS is necessary, which would enable criteria for further audit regarding DDI. Staff training should be addressed to improve transfer systems for CS. Antenatal risk assessment and congruence with role delineation and service delivery capacity is important. What is known about the topic? The 30-min rule has been cited and used globally as best practice, despite the low level of supporting evidence. What does this paper add? There is no strong evidence that DDIs of less than 30 min are associated with improved neonatal or maternal outcomes. A DDI of greater than 30 min but less than 75 min confers some benefit, but this is tempered by the urgency of the CS. What are the implications for practitioners? Urgent CS should occur as soon as possible, but there is insufficient evidence to support a definite time frame, such as 30 min. A consistency of approach and nomenclature in describing the urgency of CS is necessary, which would enable criteria for further audit regarding DDI. Staff training should be addressed regarding efficient systems during transfer for CS. Careful antenatal risk assessment and congruence with role delineation and service delivery capacity is important in making recommendations for place of birth for women.