Delayed Decision to Delivery Time for Caesareans

The time from decision to delivery for caesarean births was one of the five higher-risk themes analyzed by a recent national Canadian panel of experts exploring knowledge gaps, promising interventions, barriers, and opportunities to spread best practice (Lefebvre, et al., 2019). Preparation for caesareans requires proper allocation of resources and supplies, planning, and collaboration across all professionals, shifts, teams, and sites. Prompt recognition and response to critical clinical scenarios enhances client safety and mitigates the severity of adverse outcomes. From a safety and medical legal perspective, time will always be “of the essence”. In the case of a bad outcome, anything that could have reasonably been done to reduce the time lapse between the decision and performance of the caesarean may appear, in retrospect, to be an obvious oversight.

Expected Outcomes

Implement standardized communication and response protocols for non-elective caesareans.

Implement formal strategies to provide targeted education and training to support and enhance the interdisciplinary team’s clinical knowledge, skills (technical and non-technical), and practical experience surrounding non-elective caesareans. 

Adopt quality indicators to monitor morbidity and mortality involving non-elective caesareans. 

Definitions and Abbreviations

• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• FHS – fetal health surveillance
• HIE - hypoxic ischemic encephalopathy
• MRP – most responsible practitioner, often a midwife, nurse practitioner or physician
• NPO – Latin abbreviation for “nothing by mouth”
• NICU – neonatal intensive care unit
• OR – operating room
• Situational awareness – deliberate and active scanning and assessing of the situation to maintain a holistic understanding of the environment in which the team is functioning

Common Claims Themes and Contributing Factors

Organizational

• Perceived and actual tolerance of unprofessional, unsafe, and / or disruptive as well as ongoing inter- and intra-professional conflicts.
• Resource and staffing challenges in responding to one or more time sensitive and competing obstetrical scenarios.
• Cumbersome or ineffective and outdated:
  • Emergency response plan for caesareans;
  • On-call and backup / second on-call processes in particular for obstetricians, anesthetists, and neonatal / pediatric teams.
• Chaotic transfers to the OR.
• Adversarial and ineffective systems reviews and recommendations arising from fetal harm incidents.

Knowledge and Judgement

• Knowledge gaps surrounding emergency response plans for caesareans.
• Ineffective team communication practices surrounding the level of urgency or time sensitivity associated with the caesarean.
• Loss of team and individual situational awareness once the caesarean is called.
• FHS not or inadequately performed once the caesarean is called including:
  • Pregnant persons being prepped for and/or in the OR awaiting team arrival;
  • Staff operating under the mistaken belief that the arrival of a critical team member (typically the obstetrician or anesthesiologist) is imminent.
• Delayed transfers of the pregnant person to the OR or delayed team and / or practitioner attendance in the OR due to lack of familiarity and prioritization of the tasks based on the caesarean classification.

Pregnant person

• Common allegations related to the shared decision making (informed choice – informed consent) conversation surrounding declined caesareans:
  • Did not understand the impact of their decision on their fetus or neonate;
  • Description of risks did not resonate, particularly risks for the fetus or neonate;
  • Use of vague, medical language, and statistics that minimize the consequences, particularly risks for the fetus or neonate.
• Risk factors impacting the decision for and timing of caesareans.

Communication 

• Hesitation and reluctance to escalate concerns about unsafe practices and care concerns and disagreements, including:
  • Delayed MRP, anesthetists, or surgical team attendance after:
    • The caesarean is called;
    • The OR is ready for the client;
  • Delayed decision / call for a caesarean;
  • Delays expediting the caesarean in the presence of changing circumstances or deteriorating pregnant person / fetus.
• Inability to effectively communicate with the pregnant person, or confirm the pregnant person’s understanding of:
  • The level of urgency and consequences associated declining the caesarean versus choosing to wait;
  • Changing circumstances prompting the recommendation for a caesarean.

Mitigation Strategies

Care Processes

• Adopt a standardized formal call schedule for on-call and backup / second on-call team members for caesarean (including anesthesia) and neonatal resuscitation; implement strategies to ensure the call schedule is readily available, easy to follow, and maintained (e.g., call schedule grid maintained and updated by admin staff). 
• Implement strategies to develop ongoing relationships with referral communities without caesarean and inter-facility transport services.
• Implement a standardized current evidence-based emergency response protocol for caesareans (Bloch, Dore, & Hobson, 2021) (Baskett, 2015a) (Baskett, 2015b) (Singh, Mehra, & Hopkins, 2018).

Additional Considerations

Examples of elements to be addressed in the emergency response protocol for caesareans:

• Adoption of an obstetrical emergency code (e.g., code OB);
• The organization’s standardized classification system or nomenclature for caesareans; 
• A standardized ‘call process’ for non-elective caesareans;
• The response plan when the first on-call team (including anesthesia), neonatal resuscitation team, or resources are unavailable or not attending in a clinically appropriate timeframe;
• Clarity as to who is expected to initiate the backup / second on-call team and resources where indicated;
• Anticipated and unanticipated transfers from other sites or the community / home birth setting;
• A standardized list of supplies for caesareans;
• A standardized list of supplies for adult and neonate resuscitation;
• A standardized pre-operative checklist;
• A standardized obstetrical surgical safety checklist;
• The need to anticipate that the pregnant person may not be nothing by mouth (NPO);
• The need to anticipate for general anesthesia;
• The specific roles and responsibilities of each team member;
• Resources and staffing availability during off-hours, weekends, and holidays.

• Implement formal strategies to review, update, and streamline (where indicated) the caesarean emergency response plan and decision aids to remove any unnecessary steps, tasks, etc. impacting decision-to-delivery intervals and effective team functioning as well as supporting ongoing alignment between policy, practice, and ongoing resource realities.

Communication

• Adopt a standardized classification system or nomenclature for communicating, documenting, and describing the scale of urgency for elective and non-elective caesareans (National Institute for Health and Care Excellence, 2021).
• In collaboration with midwives, physicians, and nurses, adopt a team communication protocol and practice that includes agreed-upon triggers prompting interdisciplinary team awareness when a complicated or higher risk delivery is anticipated or a pregnant person with risk factors is admitted.

Shared Decision Making (Informed Choice-Informed Consent)

Strategies for Midwives and Physicians

• Ensure complete and timely documentation of the shared decision making (informed choice-informed consent) discussions surrounding recommendations for a non-elective caesarean; if an informed consent / decline form is used, ensure it is accompanied by complete and timely documentation in the health record.

Safety Culture

• Implement formal strategies to develop and maintain a work environment which supports and expects:
  • Interprofessional collaboration and collegiality (Romijn, De Bruijne, Teunissen, Wagner, & De Groot, 2018);
  • Zero tolerance of intra- and inter-disciplinary bullying and intimidation;
  • Assertive and respectful questioning and challenging of unsafe practices;
  • Early response to suspected and actual pregnant person and / or fetal deterioration, including seeking assistance from peers and other resources (e.g., rapid response teams where in place).
• Adopt a standardized, formalized, and program-specific chain of command (escalation) protocol for the rapid escalation of unresolved care concerns or disagreements related orders and / or decisions related to FHS during labour (Provincial Council for Maternal and Child Health, 2022) (Agency for Healthcare Research and Quality, 2017).

Team Training and Education

• Implement formal strategies to support and enhance the teams’ clinical knowledge, skills (technical and non-technical), and practical experience surrounding the non-elective caesarean including (but not limited to), scheduled interprofessional and cross-department skill drills and simulations (Flentje, Papageorgiou, von Kaisenberg, & Eismann, 2022) (Gavin & Satin, 2017) (Brogaard, et al., 2022).
• Ensure the team training and education strategies consider or involve: 
  • Team situational awareness (‘helicopter view’) and human factors;
  • Program areas or sites with limited practical experience with obstetrical emergencies (e.g., low volume birth sites and rural sites);
  • Unregulated care providers (where employed), locums, travel, agency, contracted care providers in additional to regulated health providers.

Equipment, Supplies and Technology

• Implement strategies to synchronize all clocks in obstetrical triage, birthing rooms, and ORs.
• Implement formal strategies to ensure the ongoing and immediate access to functioning equipment and supplies required for non-elective caesareans.

Monitoring and Measurement

• Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving non-elective caesareans resulting in harm or death; incorporate system thinking and human factors concepts into the review process (The Society of Obestricians and Gynaecologists of Canada, 2021) (Perinatal Services BC, 2017) (College of Physicians and Surgeons of Manitoba, 2020) (Machen, 2023). 
• Adopt standardized quality indicators for the decision to delivery time for caesareans (Calder, et al., 2019).
• Incorporate learning from local, provincial, and national non-elective caesarean incidents and data into local protocols as well as staff and client education and training.

References

• Agency for Healthcare Research and Quality. (2017). Safe Medication Administration: Oxytocin. Retrieved from https://www.ahrq.gov/hai/tools/perinatal-care/modules/strategies/medication/tool-safe-oxytocin.html
• Baskett, T. F. (2015a). Essential Management of Obstetric Emergencies (5th ed.). Bristol: Clinical Press.
• Baskett, T. F. (2015b). Preparedness for Emergency “Crash” Caesarean Section. J Obstet Gynaecol Can, 37(12), 1116–1117.
• Bloch, C., Dore, S., & Hobson, S. (2021). Committee Opinion No. 415: Impacted Fetal Head, Second-Stage Cesarean Delivery. J Obstet Gynaecol Can, 43(3), 406−413. doi:10.1016/j.jogc.2021.01.005
• Brogaard, L., Lauridsen, K. G., Løfgren, B., Krogh, K., Paltved, C., Boie, S., & Hvidman, L. (2022). The effects of obstetric emergency team training on patient outcome: A systematic review and meta-analysis. Acta Obstet Gynecol Scand, 101, 25-36. doi:10.1111/aogs.14263
• Calder, L. A., Bowman, C. L., Yang, Q., Gondocz, T., Young, C., Zhang, C., . . . G., L. (2019). A quality indicator framework for high-risk areas in obstetrical care. Canadian Medical Protective Association.
• College of Physicians and Surgeons of Manitoba. (2020). Maternal and Perinatal Health Standards Committee. 2020 Annual Report. 
• Flentje, M. H., Papageorgiou, S., von Kaisenberg, C., & Eismann, H. (2022). Influence of presence in an inter-professional simulation training of the emergency caesarean section: a cross-sectional questionnaire study. Archives of gynecology and obstetrics, 305(6), 1499–1505. doi:10.1007/s00404-022-06465-9
• Gavin, N. R., & Satin, A. J. (2017). Simulation Training in Obstetrics. Clinical obstetrics and gynecology, 60(4), 802–810. doi:10.1097/GRF.0000000000000322
• Lefebvre, G., Calder, L., De Gorter, R., Bowman, C., Bell, D., Bow, M., & National Panel on Quality Improvement in Obstetric. (2019). Recommendations From a National Panel on Quality Improvement in Obstetrics. Journal of obstetrics and gynaecology Canada, 41(5), 653-659. doi:doi.org/10.1016/j.jogc.2019.02.011
• Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
• National Institute for Health and Care Excellence. (2021). Caesarean birth. Retrieved from https://www.nice.org.uk/guidance/ng192
• Perinatal Services BC. (2017). Perinatal and Maternal Mortality & Morbidity Review Process. Retrieved from http://www.perinatalservicesbc.ca/health-professionals/guidelines-standards/perinatal-maternal-mortality-morbidity-review-process
• Provincial Council for Maternal and Child Health. (2022). Safe administration of oxytocin. 
• Romijn, A., De Bruijne, M., Teunissen, P., Wagner, C., & De Groot, C. (2018, 10). Interprofessional collaboration among care professionals in obstetrical care: are perceptions aligned? International Journal of Integrated Care, 18(s2), 228.
• Singh, S. S., Mehra, N., & Hopkins, L. (2018). No. 286-Surgical Safety Checklist in Obstetrics and Gynaecology. J Obstet Gynaecol Can, 40(3), E237-E242. doi:10.1016/j.jogc.2018.01.018
• The Society of Obestricians and Gynaecologists of Canada. (2021). Maternal mortality review committees guide.