Royal College of Obstetricians and Gynaecologists

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Royal College ofObstetricians andGynaecologists
Setting standards to improve womens health
Risk Management and Medico-Legal Issues In
Womens Health Joint RCOG/ENTER Meeting
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Audit of decision to delivery interval for
emergency caesarean sections in 2007

• Michelle Judd
• Consultant Obstetrician

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• rural location
• Bury St Edmunds
• market town
• 2500 deliveries per year
• 25 CS rate

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Aims and objectives

• To ensure that the urgency of an emergency CS is
  documented in a standardised way
• To use timing standards which have been agreed
  between obstetric and anaesthetic staff
• To review decision to delivery interval for all
  emergency CS
• Required audit for the units CNST Level 3
  assessment

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Audit standards
CS grade Indication Decision to delivery interval (minutes)
1 Immediate threat to life of woman or fetus 30
2 Maternal or fetal compromise, not immediately life threatening 60
3 Needing early delivery but no maternal or fetal compromise To be delivered within an acceptable time
4 Elective cases Booked on elective CS lists
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Audit method

• Review decision to delivery interval for all
  emergency CS
• Data collected monthly using emergency CS diary
• Diary recorded
• Reason for CS
• Grade of CS
• Decision time for CS
• Time of delivery
• Results presented at monthly Clinical Governance
  meetings

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Emergency CS decision to delivery interval
standard achieved in 2007
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Audit results -Standards achieved for 2007

• Grade 1 CS target achieved 98
• Grade 2 CS target achieved 78
• Grade 3 CS target achieved 100

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Results reason for delay
Reason for delay No.
Anaesthetic difficulty 12 24
Surgical difficulty 3 6
Delay in transfer to theatre 15 28
Another obstetric case in theatre 12 24
Lack of staff/awaiting arrival staff 6 11
Patient needed time to make decision 2 4
Unknown (notes missing) 1 2
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Results length of delay
Delay (min) Anaesthetic problem Delay in transfer to theatre Other obstetric case in theatre Other causes
1-10 4 11 4 6
11-20 5 2 - 2
21-30 2 - 1 2
gt30lt60 2 2 3 1
gt60 - - 4 -
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Results length of delay
Delay (minutes) Number
1-10 25 49
11-20 9 18
21-30 5 10
gt30lt60 8 16
gt60 4 7
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Summary of delays

• Anaesthetic difficulties
• Unavoidable delay
• Most related to maternal obesity
• Use of regional anaesthesia is safest option
• Delay in transfer to theatre
• Avoidable delay
• CDS Coordinator to be responsible for timely
  transfer to theatre
• Lack of obstetric theatre
• Avoidable delay
• Feasibility of providing another theatre when
  there is a second obstetric emergency

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BMI at booking appointment
BMI Midwifery-led care Consultant-led care
18.5-24.9 56 40
25-29.9 30 20
30-34.9 7 20
35 or greater - 10
Not recorded 7 10
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Summary of delays

• Anaesthetic difficulties
• Unavoidable delay
• Most related to maternal obesity
• Use of regional anaesthesia is safest option
• Delay in transfer to theatre
• Avoidable delay
• CDS Coordinator to be responsible for timely
  transfer to theatre
• Lack of obstetric theatre
• Avoidable delay
• Feasibility of providing another theatre when
  there is a second obstetric emergency

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.and finally

• Level 1 CNST in March 2004
• Level 2 CNST in March 2006
• Level 3 CNST in January 2008

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Royal College ofObstetricians andGynaecologists
Setting standards to improve womens health
Risk Management and Medico-Legal Issues In
Womens Health Joint RCOG/ENTER Meeting
Please turn off all mobile phones and pagers