Is Faster Better? Relationships of Cesarean Acuity with Risk of Low Apgar Scores and Fetal Acidemia

Timely response to obstetrical emergencies is highly desired. The recommendation for decision-to-incision (DTI) time in cesarean delivery (CD) of not more than 30 minutes was issued to prevent neonatal hypoxic-ischemic morbidities. We analyzed the efficiency with which an institutional-specific CD acuity classification system (emergent case: target DTI ≤ 15 minutes; urgent case: target DTI ≤ 30 minutes) reflected in the actual DTI time, Apgar scores, and newborn acid-base status.

Data on all 610 cesarean sections (CSs) performed over a 14-month period at a tertiary medical center were retrospectively extracted. Cases grouped by target DTI time categories were compared for proportions in low Agar scores and fetal acidosis. Multivariable regression was used to identify clinical variables associated with the need for neonatal resuscitation.

During the study period, 60 (10%) of CSs were emergent, 296 (49%) urgent, and 254 (41%) elective. The target DTI ≤ 15 minutes was achieved in 68% of emergent CSs with 93% having a DTI ≤ 30 minutes. Among urgent surgeries, the target DTI ≤ 30 minutes was reached in 48% of cases with 83% having DTI ≤ 45 minutes. Compared with both urgent and scheduled procedures the incidence of newborn acidosis and Apgar scores ≤4 and ≤7 was the highest among emergent CSs. The proportion of moderate and severe acidosis for deliveries with DTI ≤ 15 minutes was significantly higher compared with procedures with DTI 16 to 30 and >30 minutes. The need for neonatal resuscitation, including intubation, was independently associated with fetal acidosis, low gestational age, surgery acuity level, general anesthesia, but not with the actual DTI time.

Adherence to tight DTI time targets is pragmatically difficult. The need for neonatal resuscitation varies with the acuity of the procedure but not with the actual DTI interval, implying that within certain time limits, the indication for surgery plays a greater role in the status of the newborn than the speed of the CS.

· Adherence to prespecified DTI times for cesarean is pragmatically difficult.. · Emergent CS had the highest proportion of newborns with acidosis and low Apgar scores despite shorter DTI.. · The need for neonatal resuscitation associated with fetal acidemia, prematurity and general anesthesia..