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Firm 'Decision-to-Incision' Time for Cesarean Questioned


DALLAS ? The 30-minute time frame for beginning a cesarean after the decision is made for one should be the suggestion it was intended to be and not the rule it has become, researchers here said.

DALLAS, June 30 ? The 30-minute time frame for beginning a cesarean after the decision is made should be the suggestion it was intended to be and not the rule it has become, researchers here said.

Outcomes were about the same for mother and child in which the "decision-to-incision" time was under or over 30 minutes, said Steven Bloom, M.D., of the University of Texas Southwest Medical Center here, and colleagues, in the July issue of Obstetrics & Gynecology.

The study examined data from more than 11,000 primary cesarean deliveries performed for an emergency indication at hospitals belonging to the Maternal-Fetal Medicine Units Network in 1999 and 2000.

Overall, 65% of these emergency cesareans began within 30 minutes of the decision to operate. About 27% started within 20 minutes and 17% began within 10 minutes.

The study did not provide a time breakdown for decision-to-incision times that went longer than 30minutes, but Dr. Bloom said it was generally not more than 60 minutes.

When the investigators analyzed various infant outcomes according to whether the decision-to-incision time had been 30 minutes or less versus 31 minutes or greater, no adverse outcomes were associated with the longer time.

More infants in the shorter-time group had an umbilical artery Ph of less than 7 (4.8% versus 1.6% of the longer group; P=.001), and more infants in the shorter group needed intubation in the delivery room (3.1% versus 1.3% in the longer group; P=.004).

There were no significant differences in infants with a low Apgar score (about 1% in each group; P=.82) or hypoxic ischemic encephalopathy (less than 1% in each group; P=.61). Three fetal deaths occurred in the shorter time frame group and none in the longer time frame group (P=.31).

No significant differences were observed for maternal outcomes such as endometritis (P=.32) or wound complications (P=.39).

The 30-minute guideline was published in the fifth Edition of Guidelines for Perinatal Care, which was published jointly by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in 2002, Dr. Bloom and colleagues noted.

"We emphasize that this guideline does not establish the 30-minute interval to be a requirement but rather a capability," they said. "The distinction between these two terms is important and we believe often overlooked"

"For example," they said, "not effecting cesarean delivery within 30 minutes is a common reason that obstetric malpractice claims are perceived to be indefensible. The implication of such perception is that the 30-minute interval is a requirement or standard for acceptable obstetric practice."

"Our observations are that obstetricians are prioritizing the timing of cesarean delivery such that those done within 30 minutes of the decision appear to have been necessary given that the infants were statistically at increased risk of compromise," the investigators said.

"Conversely, most infants delivered for emergency indications do not experience compromise whether delivered less than or greater than 30 minutes from the decision to operate," they wrote.

The authors pointed out several limitations of the study:

  • The study was observational in design and there was no option to randomize patients to delivery before or after the 30-minute time point.
  • The study was limited to university hospitals and may not be generalizable to other environments.

They concluded that "we are forced to confront the fact that a benchmark has been established that can never be experimentally tested."

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