Decision to delivery interval and perinatal outcome for category one caesarean section in a tertiary

Background: The Royal college of obstetrics and gynaecology and the American College of Obstetrics and Gynecology recommend a maximum interval of 30 minutes between the decision to perform an emergency caesarean section and delivery of the baby (DDI), when there is an immediate life threatening condition to the mother or baby. So far, this has been a herculean task in the majority of the developing nations. Objectives: To determine the decision-to-delivery interval and perinatal outcome for category one caesarean section in Aminu Kano Teaching Hospital, Kano. Methods: A One Year Retrospective study of category one caesarean section performed in Aminu Kano st st Teaching Hospital between 1 January 2018 and 31 December 2018. Results: The mean DDI was 114.4 minutes. Only 6.2% were delivered within the recommended 30 minutes DDI. There was no significant association between the DDI and adverse perinatal outcomes but a significant association was found between the indication for the crash caesarean section and adverse perinatal outcome. The major determinants of prolonged DDI were maternity unit delays, anaesthetist delay, patient refusal to sign consent and busy operating rooms. Conclusion: The mean DDI was longer than the recommended DDI of 30 minutes. Although this had no impact on perinatal outcome in this study. However, the perinatal outcome largely depended on the indication for the caesarean section.


Introduction
Emergency caesarean section is indicated when delivery can lead to a reduction in the risk to the life 1 of the mother or fetus.In the past, caesarean section was traditionally classified into elective and emergency.This has been found to be of limited value for data collection and audit of obstetric and anaesthetic outcomes because the spectrum of urgency that occurs in obstetrics is 2 lost within a single emergency category.In 2002, 3 Lucas et al proposed a new classification after a 2part study that involved obstetricians and anaesthetists based on clinical definitions and came up with four categories.Category one caesarean section is that in which there is an immediate threat to life of woman or fetus and requires immediate delivery while in category two, the threat is not immediate.Category three is that in need of early delivery but there is no compromise whereas category four is done at a time to suit the patient and maternity unit.Decision-to delivery interval is that interval between a decision to perform an emergency caesarean section and the actual delivery of the 4 baby.In life threatening conditions, i.e category one caesarean section, the American College of Obstetrics and Gynaecology and the Royal College of Obstetrics and Gynaecology recommend a maximum interval of 30 minutes between the decision to perform an emergency caesarean section 5 and delivery of the baby.Category 2 caesarean section is safely performed within 60 to 75 minutes while category 3 caesarean section is performed within hours.In Germany, 64.6% of category one caesarean sections are performed within 10 minutes of decision while 98.9% of all category one caesarean sections are done within 20 minutes of 6 decision to perform them.Every obstetric unit should have the capacity to perform emergency caesarean section in 30min of decision for fetal safety.This is however not obtainable in the vast majority of the developing nations.The indications for crash caesarean section include cord prolapse, failed instrumental birth with fetal compromise, maternal cardiac arrest, abnormal fetal scalp blood sample/ pH (high lactate or pH < 7.2), confirmed fetal blood (Apt's test) indicating ruptured fetal blood vessels e.g Vasa Praevia, placental abruption with a live baby, placenta praevia with major haemorrhage, identified irreversible abnormalities on the CTG that require immediate delivery (sustained fetal bradycardia and prolonged deceleration > 3min), uterine rupture and

Materials and method
This is a retrospective study carried out in the department of Obstetrics and Gynaecology of Aminu Kano Teaching Hospital, Kano, Kano state.Labour ward and theatre registers were used to extract file numbers of patients that had category 1 caesarean section and their case notes were retrieved from the medical records department of the hospital.The case records and antenatal data of all the women who had category1 caesarean section st at Aminu Kano Teaching Hospital from 1 January st 2018 to 31 December 2018 were retrieved and analysed.Data was analysed using SPSS version 21.
Qualitative data was analysed using Fisher's test of statistical significance.Frequency and percentages were used for quantitative variables.

Results
A total of 2999 deliveries occurred during the study period of one year.Out of these, 584 were caesarean sections and 14 were laparotomies for ruptured uterus giving a caesarean section rate of 19.9%.Of this, 333 were performed as emergency.Category one caesarean section accounted for 77 cases giving an overall prevalence of 2.6% of the total deliveries, 12.9% of the total caesarean sections and 23.12% of emergency caesarean sections.Fourty eight folders were retrieved giving a retrieval rate of 62.3%.Table 1 shows the sociodemographic characteristics of the study population.The age of the study population ranged between 20 and 40 years with a mean of 29.9 years.Majority of the women fell in the 30-34 years age group (31.3%).Their parity distribution ranged from 0-9 with primigravidity constituting 25% while multigravidity and grandmultiparity accounted for 37% each.Majority of the women presented at term (64.6%) while only 8.3% were post term.Eighty seven percent of the women were either booked at AKTH or another facility while 13% were unbooked.It was observed that adverse perinatal outcome occurred more frequently in some indications than with others.This was seen in 100% of those with ruptured uterus, 50% of those with placenta praevia and major haemorrhage, 40% 0f abruptio placenta and live baby, 37.5% of cord prolapse, 25% of pathological CTG and 6.7% of patients with fetal distress.The association between indication for caesarean section and occurrence of adverse perinatal outcome was statistically significant.
The reasons for delay in achieving the WHO recommended decision to delivery interval of 30 minutes for category 1 caesarean section are presented in table 5.The commonest cause of delay was shifting patients to theatre during the change over period for labour ward and theatre staff, occurring in 48.9%.This was followed by anaesthetist delay in 13.3%.Patient delay in obtaining consent for surgery and resuscitation accounted for 11.1% each.Lack of theatre space was the reason in 8.9% of cases while delay in getting blood was the least occurrence found in 6.7% of the cases.Table 6 shows the relationship between the decision delivery interval and occurrence of adverse perinatal outcome.No statistically significant association was found between the decision to delivery interval and occurrence of adverse perinatal outcome.Table 7 shows the relationship between indication for category one caesarean section and occurrence of adverse neonatal outcome.A statistically significant association was found between the various indications for caesarean section and occurrence of adverse neonatal outcome.

Discussion
The prevalence of category one caesarean section from this study is 2.57% of total deliveries.This is lower than the 3.8% reported in a study by Leah et.

Conclusion
The mean DDI for category one caesarean section at Aminu Kano Teaching Hospital was found to be 114.4minutes which is high compared to WHO recommendation of 30 minutes.Only 6.2% of the caesarean sections were performed within the 30 minutes recommended DDI for category one caesarean section.However, the DDI had no impact on perinatal outcomes in this study.Achieving the 30 minutes DDI may not be feasible in most Nigerian hospitals.Maternity unit delays constitute the major delays in carrying out emergency caesarean sections.This need to be reduced in order to overcome the 3rd phase delay in receiving the definitive care by women with labour

Table 5 : Reasons for delay in achieving recommended DDI of 30 minTable 6 : Relationship between DDI and adverse perinatal outcome
Ibom Med.J. Vol.13 No.2 May, 2020Attah Raphael Avidime et alDecision to delivery interval and perinatal outcome...

Table 7 : Relationship between indication for CS and adverse perinatal outcome Adverse outcome Total Statistical test
18al.The mean age of the women is 29.9 years.This 8 by Clare et al in Singapore, 27.4 minutes by 12 Mackenzie et al in the United Kingdom, 36.3 20 minutes by Gupta et al in India, 60 minutes by 4 Hirani et al in Tanzania and 106.3 minutes by 15 Chukwudi et al in University of Benin Teaching Hospital.This is however lower than 137 minutes 11 reported by Yakasai et al in Kano and 511 minutes The shortest mean DDI in this study was observed in cases of cord prolapse.This is the same as the 11 finding of Yakasai et al in a previous study in the RecommendationsThe hospital management should encourage effective communication and team work between the doctors, nurses and other adhoc staff to ensure timely delivery of services.Proper documentation should always be done in clear hand writing by doctors in patient case notes as well as appropriate filling of the CS proforma and post-operative notes.Increasing the number of heath personnel; doctors, nurses, and especially anesthetists will go a long way in reducing DDI.Limitations1.Difficulty retrieving case notes from record office and missing folders.2. Confounding factors such as prematurity and late presentation of patients contributed to occurrence of adverse outcomes.3. Follow-up to determine late neonatal deaths was not feasible.