Background
Many resource-constrained centres fail to meet the international standard of 30 min of decision-to-delivery interval (DDI) of Category-1 crash caesarean deliveries. However, specific scenarios like acute foetal bradycardia and antepartum haemorrhage necessitate even faster interventions.
Methods
A multidisciplinary team developed a “CODE-10 Crash Caesarean” rapid response protocol to limit DDI to 15 min. A multidisciplinary committee analysed a retrospective clinical audit of maternal–foetal outcomes over 15 months (August 2020–November 2021), and expert recommendations were sought.
Results
The median DDI of twenty-five patients who underwent a “CODE-10 Crash Caesarean delivery” was 13 ± 6 min, with 92% (23/25) of DDIs falling below 15 min. Seven neonates required intensive care for more than 24 h with no maternal or neonatal mortality. DDIs during office and non-office hours were not significantly different (12.5 ± 6 min vs 13 ± 5 min, p = 0.911). Transport delays caused the two instances of DDI > 15 min.
Conclusion
The novel "CODE-10 Crash Caesarean" protocol may be feasible for adoption in a similar tertiary-care setting with appropriate planning and training.
Keywords : Caesarean section · Decision-to-delivery interval · Quality improvement · Patient safety
During several obstetric emergencies, immediate caesarean deliveries are required. The Royal College of Obstetricians and Gynaecologists and the American College of Obstetricians and Gynecologists have set a standard of 30 min for decision-to-delivery interval in Category 1 (Urgent) caesarean deliveries [1–3]. However, these standards are rarely met, particularly in low-resource settings, with several authors questioning their value [4, 5].
However, in scenarios like acute foetal bradycardia or antepartum haemorrhage, a delivery delay of even 30 min can compromise maternal–foetal outcomes. A novel "CODE-10 Crash Caesarean" announcement promptly activates the multidisciplinary team required to perform a "crash" caesarean delivery within minutes. Thereby, we hoped to further limit the decision-to-delivery interval (DDI) [6], to 15 min by adopting a modified multidisciplinary protocol [7] in our tertiary care setting. This study evaluates the feasibility of the new "CODE-10 Crash Caesarean" by analysing maternal–foetal outcomes and its operational challenges over 15 months in a tertiary-care hospital in India. In addition, we further discuss pragmatic strategies to reduce DDI in crash caesarean deliveries.
"CODE-10 Crash Caesarean" is an emergency protocol, activated by the obstetric team via the hospital public address system, when the need to perform a Category-1 "Crash" emergency caesarean delivery is identified. In our centre, we take the following as indications for "CODE-10 Crash Caesarean": (i) acute foetal bradycardia (or a single deceleration lasting more than 3 min) [8], (ii) severe antepartum haemorrhage with foetal or maternal compromise, (iii) cord prolapse and (iv) suspected uterine rupture or scar dehiscence. Notably, not all pathological cardiotocogram (CTG) traces [9] are considered as indications. This protocol rapidly alerts all concerned team members from the three departments— Obstetrics and Gynaecology, Anaesthesiology and Neonatology, who rush to the labour room operation theatre (LR-OT), to rapidly facilitate foetal delivery within 15 min (Fig. 1). The primary surgeon/team leader is always an OBG consultant (faculty) with 2–10 years of surgical expertise. Another consultant of similar grade or an OBG resident often serves as the assistant surgeon.
"CODE-10 Crash Caesarean" was conceptualised by four senior obstetrician-gynaecologists with 30–50 years of experience in maternal–foetal medicine in our tertiary care teaching hospital, conducting ~ 1500 deliveries per year. The concept was discussed before a multidisciplinary committee, consisting of representative consultants and nurses (with 2–15 years of clinical experience) from Obstetrics & Gynaecology, Anaesthesiology and Neonatology. These participants were the primary duty staff who were most likely to attend crash caesarean deliveries. After the first round of discussions, a preliminary protocol was formulated, and this new code was trialled as part of the existing hospital emergency code directory. The pertinent clinical staff of all involved departments were familiarised with the new system, via on-site training sessions, following which "CODE-10 Crash Caesarean" underwent a trial phase of 6 months. At the end of the trial phase, the second round of discussions was held, where the operational directives, depicted in Fig. 2, were finalised and disseminated via a final training session to all concerned department personnel. The obstetric team oversaw data collection and analysis of the "CODE-10 Crash Caesarean" audit daily.
With Institutional Ethics Committee clearance, the maternal– foetal outcomes between 1 August 2020 and 1 November 2021 were analysed in the third round of committee discussion. Qualitative observations and recommendations for improving the novel CODE-10 were sought. All consecutive patients who underwent a "CODE-10 Crash Caesarean" delivery during the study period were included for analysis.
The primary outcome is the DDI, which must be limited to 15 min, which is a much more stringent standard than advocated by international organisations (30 min) [5] but may ensure better maternal–foetal outcomes even if the DDI overshoots by a few minutes. Secondary outcomes include maternal and foetal morbidity/mortality. Differences in DDI between office hours (9:00 am–5:00 pm) and nonoffice hours (5:01 pm–8:59 am) were analysed to evaluate the performance of the code with minimal staffing. This was detected as nonparametric using a Shapiro–Wilk test and was compared using the Mann–Whitney U test, with p ≤ 0.05 (2-tailed) denoting statistical significance. Data analysis was performed in SPSS version 26 (IBM Corp. Armonk, USA).
Our CODE-10 team achieved an impressive success rate
in improving on international standards by limiting DDI to
15 min to all but two cases of Category-1 caesarean deliveries.
Interdepartmental collaboration and accountability
have been integral in materialising this essential code in our
centre. No longer is the obstetric team scrambling to alert
multiple on-call specialists about an imminent emergency
caesarean delivery, and the entire process has been simplified
to a 5 second phone announcement. While the code
was systematically implemented, the daily monitoring of its
progress enabled the obstetric team to address practical difficulties
associated with staffing patterns, equipment failures
and transportation mechanisms in a real-time fashion. This
has undeniably led to streamlined obstetric emergency care,
even during non-office hours. With this ongoing or "living"
clinical audit, we hope a similar positive outcome will continue
to be observable in the coming years.
Other high-volume centres in India and resource-constrained
settings across the globe often struggle to limit
DDI to even 30 min [15–19], and as a consequence, some
have reported worse maternal and foetal outcomes. To the
best of our knowledge, the current audit is the first study
from India demonstrating that such rapid response teams
can attain the 15-min DDI target. These ambitious targets
were previously limited to centres in developed nations that
enacted similar rapid response colour codes, which reported
no significantly different neonatal outcomes [20–25]. However,
some authors have warned that such novel codes can be overused for non-life-threatening indications, potentially
compromising maternal safety for a shorter DDI [26].
Recently, Boriboonhirunsarn and Sunsaneevithayakul [27] inducted a similar code "Code Blue", in a resourceconstrained centre to limit DDI to 30 min. However, they did not limit interventions to acute bradycardia as we did, but rather intervened in all NICHD Category III CTG patterns [9]. They demonstrated a significant reduction in DDI in a large cohort of 150 patients; to a mean of 22 min (after code induction) from 52.5 min (prior to code induction) and did not observe any significantly different neonatal outcomes.
This pilot study is unique to the best of our knowledge. Compared to similar studies, the indications for a "CODE- 10 Crash Caesarean" delivery are highly selective—only acute foetal bradycardia or "a single prolonged deceleration of greater than 3 min" (out of all other pathological CTG patterns) has been considered for such rapid procedures, along with other conventional Category-1 indications. This prohibited unnecessary crash caesarean deliveries in several women with pathological/non-reassuring CTG traces, who were managed more conservatively. Relative to other pathological patterns, the acute bradycardia foretells a hyperacute foetal insult, which requires a rescue within 10–15 min and not 30 min. We believe that similar multidisciplinary teams can easily adapt our novel code and expert recommendations to minimise DDI in their tertiary care centres.
Consequently, all aspects of this CODE-10 protocol may not be generalisable to all delivery points, i.e. secondary care centres without round-the-clock anaesthesia, neonatology and adequate clinical as well as support staff. However, DDI still can be optimised using our general guidelines for the obstetric team. An uncoordinated team can compromise maternal safety during such hyper-accelerated interventions, even before the patient reaches the operation theatre, such as patient transport and medicine safety. Surgeons must anticipate anaesthetic/operative delays and complications in high-risk patients with hypertensive, diabetic, cardiac or bleeding disorders.
The current study is primarily limited by the lack of a historical control data as a reference, for analysing DDI improvements in the same setting. Due to the rapid nature of the code and limited personnel involved during non-office hours, sub-intervals of DDI like "transfer time" or "anaesthetic time" could not be reliably measured in this series [6].
Conflict of interest The authors declare that they have no conflict of interest.
Ethical consideration This study was performed in line with the principles of the Declaration of Helsinki. Ethical approval was provided by the Rajagiri Hospital Institutional Ethics Committee (ref. RAJH/A/2021/008). Informed consent was obtained from all individual participants included in the study.
