National cross sectional survey to determine whether the decision to delivery interval is critical in emergency caesarean section
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《英国医生杂志》
1 National Collaborating Centre for Women's and Children's Health, London NW1 4RG, 2 School of Human Development, Queen's Medical Centre, Nottingham NG7 2UH
Correspondence to: J Thomas JThomas@rcog.org.uk
Abstract
In the United Kingdom, the Department of Health has allocated ￡1.5bn ($2.7bn; 2.3bn) to cover obstetric litigation over the next five years.1 Many cases involve possible intrapartum antecedents of cerebral palsy. To help improve intrapartum fetal care the National Institute for Clinical Excellence clinical guideline on electronic fetal monitoring recommends that "in cases of suspected or confirmed acute fetal compromise, delivery should be accomplished as soon as possible, accounting for the severity of the fetal heart rate abnormality and relevant maternal factors. The accepted standard has been that, ideally this should be accomplished within 30 minutes."2 The ability of hospitals to meet this standard was assessed in the national sentinel caesarean section audit.3
A systematic review found limited research to underpin this standard, and 30 minutes is an arbitrary threshold.2 4-7 It has been suggested that rapid delivery may be dangerous in itself for the fetus. However, the most compromised babies are most predisposed to a poorer outcome and are also often delivered with the least delay, and this needs to be taken into account when assessing the effects of a rapid delivery.8 9 Rapid delivery may also increase the risk of maternal mortality, as a result of surgery or factors such as general anaesthesia.10
Perceived urgency can be critical in motivating a caesarean section. A grading system for urgency was evaluated in the national sentinel caesarean section audit.3 Using data from this audit, we examined the association between decision to delivery interval and baby and maternal outcomes, after adjustment for clinical factors associated with poor fetal, neonatal, or maternal outcome.
Methods
Between 1 May 2000 and 31 July 2000, 17 780 singletons were delivered by emergency caesarean in England and Wales. Perceived urgency was classified as grade 1 for 26.0% (n = 4622), grade 2 for 51.3% (n = 9122), and grade 3 for 20.8% (n = 3689). Seven per cent of the women were delivered within 15 minutes and 22% within 30 minutes. Overall, 46% (n = 2137) of women with grade 1 urgency, 16% (n = 1422) with grade 2, and 9% (n = 330) with grade 3 were delivered within 30 minutes (table 1).
Table 1 Grade of urgency for all emergency caesarean sections and decision to delivery interval (minutes). Values are numbers (percentages) of women
The most common primary indications for emergency caesarean were presumed fetal compromise, intrauterine growth retardation or an abnormal cardiogram (35%), and failure to progress (32%). Presumed fetal compromise was the primary indication for most (66%) cases with grade 1 urgency (table 2).
Table 2 Grade of urgency for all emergency caesarean sections and primary indication for caesarean section (n=17 780). Values are numbers (percentages) of women
Of the babies born by emergency caesarean, 3.4% (n = 586) had a five minute Apgar score of < 7 and 1.0% (n = 175) had a five minute Apgar score of < 4. The stillbirth rate was 3.0 per 1000 singletons delivered by emergency caesarean section (n = 53). Of these, most (n = 43) were reported to be grade 1 urgency, six were grade 2 urgency, and three were grade 3 urgency. Grade of urgency was not known for one baby; the primary indication for caesarean was presumed fetal compromise.
Of the women who had an emergency caesarean 13% (n = 2283) needed special care. Of these, 0.43% (n = 80) were admitted to an intensive care unit. Women who were delivered with short (< 30 minutes) or long (> 75 minutes) decision to delivery intervals were more likely to require special care (table 3).
Table 3 Association between decision to delivery interval, clinical factors, five minute Apgar scores of <7 and <4, stillbirth, and maternal requirement for special care
Unadjusted odds ratios showed that babies delivered within 15 minutes had poorer outcomes compared with babies delivered after 30 minutes (table 3).
Compared with babies delivered within 15 minutes, the adjusted odds ratio for five minute Apgar scores of < 7 were not significantly different for babies delivered between 16 and 75 minutes. Babies delivered after 75 minutes, however, had significantly higher odds of five minute Apgar scores of < 7 (odds ratio 1.7, 95% confidence interval 1.2 to 2.4). Similar trends were seen for five minute Apgar scores of < 4 (75 minutes 1.4, 0.7 to 2.5) and stillbirth (75 minutes 1.8, 0.7 to 4.2), but this did not reach statistical significance These odds ratios were adjusted for primary indication for caesarean, intrapartum fetal monitoring, grade of urgency, and type of anaesthesia (table 3).
We repeated this analysis with cases delivered within 30 minutes as the reference group. We found no significant difference in the odds of a poor outcome for babies delivered in less than 30 minutes compared with those delivered between 31 and 75 minutes (1.1, 0.9 to 1.4 for five minute Apgar score of < 7). Babies delivered after 75 minutes, however, had an 80% increased odds of a five minute Apgar score of < 7 (1.8, 1.3 to 2.4). Similar non-significant trends were seen for five minute Apgar scores of < 4 and stillbirths.
Women who were delivered after 75 minutes had a 50% increase in adjusted odds of requiring special care after delivery compared with women delivered within 15 minutes (1.5, 1.2 to 1.8). We found no difference between the odds of this outcome between a delivery interval of 15 minutes and intervals up to 75 minutes (table 3).
Women who were delivered after 75 minutes had a 60% increase in odds of requirement for special care compared with women delivered within 30 minutes (1.6, 1.4 to 1.9). We found no difference in maternal outcome in women delivered between 31 and 75 minutes (1.1, 0.9 to 1.2).
Discussion
Eddy JW. Is childbirth safe in the UK and are there enough obstetricians? Letter to a chief executive. Hosp Med 2000;61: 204-6.
Royal College of Obstetricians and Gynaecologists. The use of electronic fetal monitoring: the use and interpretation of cardiotocography in intrapartum fetal monitoring. No 8. London: RCOG Press, 2001.
Thomas J, Paranjothy S, and Royal College of Obstetricians and Gynaecologists: Clinical Effectiveness Support Unit. The national sentinel caesarean section audit report. London: RCOG Press; 2001.
Schauberger CW, Rooney BL, Beguin EA, Schaper AM, Spindler J. Evaluating the thirty minute interval in emergency cesarean sections. J Am Coll Surg 1994;179: 151-5.
Roemer VM, Heger-Romermann G. . Zeitschrift Geburtshilfe Perinatol 1992;196: 95-9.
Chauhan SP, Roach H, Naef RW, Magann EF, Morrison JC, Martin JN Jr. Cesarean section for suspected fetal distress. Does the decision-incision time make a difference? J Reprod Med 1997;42: 347-52.
Dunphy BC, Robinson JN, Sheil OM, Nicholls JSD, Gillmer MDG. Caesarean section for fetal distress, the interval from decision to delivery, and the relative risk of poor neonatal condition. J Obstet Gynaecol 1991;11: 241-4.
MacKenzie IZ, Cooke I. Prospective 12 month study of 30 minute decision to delivery intervals for "emergency" caesarean section. BMJ 2001;322: 1334-5.
James D. Caesarean section for fetal distress. BMJ 2001;322: 1316-7.
Confidential Enquiries into Maternal Deaths. Why mothers die 1997-1999: the fifth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. No 5. London: RCOG Press, 2001.
Zeger SL and Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986;42: 121-30.
American College of Obstetricians and Gynecologists technical bulletin. Fetal heart rate patterns: monitoring, interpretation, and management. No 207, Jul 1995 (replaces No 132, Sept 1989). Int J Gynaecol Obstet 1995;51: 65-74.
MacKenzie IZ, Cooke I. What is a reasonable time from decision-to-delivery by caesarean section? Evidence from 415 deliveries. Br J Obstet Gynaecol 2002;109: 498-504.
Goodwin TM, Belai I, Hernandez P, Durand M, Paul RH. Asphyxial complications in the term newborn with severe umbilical acidemia. Am J Obstet Gynaecol 1002;167: 1506-12.
Lertakyamanee J, Chinachoti T, Tritrakarn T, Muangkasem J, Somboonnanonda A, Kolatat T. Comparison of general and regional anesthesia for cesarean section: success rate, blood loss and satisfaction from a randomized trial. J Med Assoc Thai 1999;82: 672-9.
Kolatat T, Lertakyamanee J, Tritrakarn T, Somboonnanonda A, Chinachot T, Muangkasem J. Effects of general and regional anesthesia on the neonate (a prospective, randomized trial). J Med Assoc Thai 1999;82: 40-5.
Dick W, Traub E, Kraus H, Tollner U, Burghard R, Muck J. General anaesthesia versus epidural anaesthesia for primary caesarean section—a comparative study. Eur J Anaesthesiol 1992;9: 15-21.
Wallace DH, Leveno KJ, Cunningham FG, Giesecke AH, Shearer VE, Sidawi JE. Randomized comparison of general and regional anesthesia for cesarean delivery in pregnancies complicated by severe preeclampsia. Obstet Gynecol 1995;86: 193-9.
Hong J-Y, Jee Y-S, Yoon H-J, Kim SM. Comparison of general and epidural anesthesia in elective cesarean section for placenta previa totalis: maternal hemodynamics, blood loss and neonatal outcome. Int J Obstet Anesth 2003;12: 12-6.(Jane Thomas, director1, S)
Correspondence to: J Thomas JThomas@rcog.org.uk
Abstract
In the United Kingdom, the Department of Health has allocated ￡1.5bn ($2.7bn; 2.3bn) to cover obstetric litigation over the next five years.1 Many cases involve possible intrapartum antecedents of cerebral palsy. To help improve intrapartum fetal care the National Institute for Clinical Excellence clinical guideline on electronic fetal monitoring recommends that "in cases of suspected or confirmed acute fetal compromise, delivery should be accomplished as soon as possible, accounting for the severity of the fetal heart rate abnormality and relevant maternal factors. The accepted standard has been that, ideally this should be accomplished within 30 minutes."2 The ability of hospitals to meet this standard was assessed in the national sentinel caesarean section audit.3
A systematic review found limited research to underpin this standard, and 30 minutes is an arbitrary threshold.2 4-7 It has been suggested that rapid delivery may be dangerous in itself for the fetus. However, the most compromised babies are most predisposed to a poorer outcome and are also often delivered with the least delay, and this needs to be taken into account when assessing the effects of a rapid delivery.8 9 Rapid delivery may also increase the risk of maternal mortality, as a result of surgery or factors such as general anaesthesia.10
Perceived urgency can be critical in motivating a caesarean section. A grading system for urgency was evaluated in the national sentinel caesarean section audit.3 Using data from this audit, we examined the association between decision to delivery interval and baby and maternal outcomes, after adjustment for clinical factors associated with poor fetal, neonatal, or maternal outcome.
Methods
Between 1 May 2000 and 31 July 2000, 17 780 singletons were delivered by emergency caesarean in England and Wales. Perceived urgency was classified as grade 1 for 26.0% (n = 4622), grade 2 for 51.3% (n = 9122), and grade 3 for 20.8% (n = 3689). Seven per cent of the women were delivered within 15 minutes and 22% within 30 minutes. Overall, 46% (n = 2137) of women with grade 1 urgency, 16% (n = 1422) with grade 2, and 9% (n = 330) with grade 3 were delivered within 30 minutes (table 1).
Table 1 Grade of urgency for all emergency caesarean sections and decision to delivery interval (minutes). Values are numbers (percentages) of women
The most common primary indications for emergency caesarean were presumed fetal compromise, intrauterine growth retardation or an abnormal cardiogram (35%), and failure to progress (32%). Presumed fetal compromise was the primary indication for most (66%) cases with grade 1 urgency (table 2).
Table 2 Grade of urgency for all emergency caesarean sections and primary indication for caesarean section (n=17 780). Values are numbers (percentages) of women
Of the babies born by emergency caesarean, 3.4% (n = 586) had a five minute Apgar score of < 7 and 1.0% (n = 175) had a five minute Apgar score of < 4. The stillbirth rate was 3.0 per 1000 singletons delivered by emergency caesarean section (n = 53). Of these, most (n = 43) were reported to be grade 1 urgency, six were grade 2 urgency, and three were grade 3 urgency. Grade of urgency was not known for one baby; the primary indication for caesarean was presumed fetal compromise.
Of the women who had an emergency caesarean 13% (n = 2283) needed special care. Of these, 0.43% (n = 80) were admitted to an intensive care unit. Women who were delivered with short (< 30 minutes) or long (> 75 minutes) decision to delivery intervals were more likely to require special care (table 3).
Table 3 Association between decision to delivery interval, clinical factors, five minute Apgar scores of <7 and <4, stillbirth, and maternal requirement for special care
Unadjusted odds ratios showed that babies delivered within 15 minutes had poorer outcomes compared with babies delivered after 30 minutes (table 3).
Compared with babies delivered within 15 minutes, the adjusted odds ratio for five minute Apgar scores of < 7 were not significantly different for babies delivered between 16 and 75 minutes. Babies delivered after 75 minutes, however, had significantly higher odds of five minute Apgar scores of < 7 (odds ratio 1.7, 95% confidence interval 1.2 to 2.4). Similar trends were seen for five minute Apgar scores of < 4 (75 minutes 1.4, 0.7 to 2.5) and stillbirth (75 minutes 1.8, 0.7 to 4.2), but this did not reach statistical significance These odds ratios were adjusted for primary indication for caesarean, intrapartum fetal monitoring, grade of urgency, and type of anaesthesia (table 3).
We repeated this analysis with cases delivered within 30 minutes as the reference group. We found no significant difference in the odds of a poor outcome for babies delivered in less than 30 minutes compared with those delivered between 31 and 75 minutes (1.1, 0.9 to 1.4 for five minute Apgar score of < 7). Babies delivered after 75 minutes, however, had an 80% increased odds of a five minute Apgar score of < 7 (1.8, 1.3 to 2.4). Similar non-significant trends were seen for five minute Apgar scores of < 4 and stillbirths.
Women who were delivered after 75 minutes had a 50% increase in adjusted odds of requiring special care after delivery compared with women delivered within 15 minutes (1.5, 1.2 to 1.8). We found no difference between the odds of this outcome between a delivery interval of 15 minutes and intervals up to 75 minutes (table 3).
Women who were delivered after 75 minutes had a 60% increase in odds of requirement for special care compared with women delivered within 30 minutes (1.6, 1.4 to 1.9). We found no difference in maternal outcome in women delivered between 31 and 75 minutes (1.1, 0.9 to 1.2).
Discussion
Eddy JW. Is childbirth safe in the UK and are there enough obstetricians? Letter to a chief executive. Hosp Med 2000;61: 204-6.
Royal College of Obstetricians and Gynaecologists. The use of electronic fetal monitoring: the use and interpretation of cardiotocography in intrapartum fetal monitoring. No 8. London: RCOG Press, 2001.
Thomas J, Paranjothy S, and Royal College of Obstetricians and Gynaecologists: Clinical Effectiveness Support Unit. The national sentinel caesarean section audit report. London: RCOG Press; 2001.
Schauberger CW, Rooney BL, Beguin EA, Schaper AM, Spindler J. Evaluating the thirty minute interval in emergency cesarean sections. J Am Coll Surg 1994;179: 151-5.
Roemer VM, Heger-Romermann G. . Zeitschrift Geburtshilfe Perinatol 1992;196: 95-9.
Chauhan SP, Roach H, Naef RW, Magann EF, Morrison JC, Martin JN Jr. Cesarean section for suspected fetal distress. Does the decision-incision time make a difference? J Reprod Med 1997;42: 347-52.
Dunphy BC, Robinson JN, Sheil OM, Nicholls JSD, Gillmer MDG. Caesarean section for fetal distress, the interval from decision to delivery, and the relative risk of poor neonatal condition. J Obstet Gynaecol 1991;11: 241-4.
MacKenzie IZ, Cooke I. Prospective 12 month study of 30 minute decision to delivery intervals for "emergency" caesarean section. BMJ 2001;322: 1334-5.
James D. Caesarean section for fetal distress. BMJ 2001;322: 1316-7.
Confidential Enquiries into Maternal Deaths. Why mothers die 1997-1999: the fifth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. No 5. London: RCOG Press, 2001.
Zeger SL and Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986;42: 121-30.
American College of Obstetricians and Gynecologists technical bulletin. Fetal heart rate patterns: monitoring, interpretation, and management. No 207, Jul 1995 (replaces No 132, Sept 1989). Int J Gynaecol Obstet 1995;51: 65-74.
MacKenzie IZ, Cooke I. What is a reasonable time from decision-to-delivery by caesarean section? Evidence from 415 deliveries. Br J Obstet Gynaecol 2002;109: 498-504.
Goodwin TM, Belai I, Hernandez P, Durand M, Paul RH. Asphyxial complications in the term newborn with severe umbilical acidemia. Am J Obstet Gynaecol 1002;167: 1506-12.
Lertakyamanee J, Chinachoti T, Tritrakarn T, Muangkasem J, Somboonnanonda A, Kolatat T. Comparison of general and regional anesthesia for cesarean section: success rate, blood loss and satisfaction from a randomized trial. J Med Assoc Thai 1999;82: 672-9.
Kolatat T, Lertakyamanee J, Tritrakarn T, Somboonnanonda A, Chinachot T, Muangkasem J. Effects of general and regional anesthesia on the neonate (a prospective, randomized trial). J Med Assoc Thai 1999;82: 40-5.
Dick W, Traub E, Kraus H, Tollner U, Burghard R, Muck J. General anaesthesia versus epidural anaesthesia for primary caesarean section—a comparative study. Eur J Anaesthesiol 1992;9: 15-21.
Wallace DH, Leveno KJ, Cunningham FG, Giesecke AH, Shearer VE, Sidawi JE. Randomized comparison of general and regional anesthesia for cesarean delivery in pregnancies complicated by severe preeclampsia. Obstet Gynecol 1995;86: 193-9.
Hong J-Y, Jee Y-S, Yoon H-J, Kim SM. Comparison of general and epidural anesthesia in elective cesarean section for placenta previa totalis: maternal hemodynamics, blood loss and neonatal outcome. Int J Obstet Anesth 2003;12: 12-6.(Jane Thomas, director1, S)