Delays in Cesarean Sections: Lessons Learned from Canadian Medico-legal Obstetrical Case Files

This study examined patterns of delay in urgent and emergent cesarean births using Canadian medico-legal case data, with a focus on intrapartum clinical decision-making, the decision-to-delivery interval (DDI), and contributing system-level factors.

We conducted a qualitative descriptive study with thematic analysis of medico-legal complaints in Canada closed between 2020 and 2024. From 639 cases involving physicians who provided obstetric care, we identified 47 cases involving delays in unplanned cesarean birth. Two reviewers independently analyzed case summaries and files using Braun and Clarke's 6-phase approach.

Of the 47 cases, 57% involved delays in the decision to proceed with cesarean birth, 34% involved both decision and DDI delays, and 9% primarily reflected delays in DDI. In most cases, the DDI exceeded the recommended 30-minute timeline, although peer experts criticized even shorter intervals in some circumstances. Several overlapping themes contributed to delays, including failure to recognize and act on an atypical or abnormal fetal heart rate tracing, communication breakdowns among healthcare professionals, and systemic and institutional limitations, including unavailable staff or operating rooms.

Delays in urgent cesarean births are multifactorial and complex. Medico-legal case analysis offers a unique lens into real-world care breakdowns, highlighting the need for improved multidisciplinary clinical training, structured communication, and institutional preparedness. These findings support targeted reforms to enhance emergency obstetric care across diverse Canadian settings.