Practice Tips

"All hospitals offering labor and delivery services should be equipped to perform an emergency cesarean delivery. The required personnel, including operating room personnel, anesthesia personnel, neonatal resuscitation team members, and obstetric attendants, should be in the hospital or readily available."¹

"Historically, the consensus has been that hospitals need to have the capability of beginning a cesarean delivery within 30 minutes of the decision to operate. However, the scientific evidence to support this is lacking. The decision-to-incision interval should be based on the timing that best incorporates maternal and fetal risks and benefits."² In some circumstances, thirty minutes is too long, e.g., uterine rupture, placental abruption, prolapse of the cord, and maternal cardiac arrest, when it may be necessary to initiate the procedure even more quickly.

Organizations should develop a written plan/process to address how an expeditious cesarean delivery will be performed when staff is available or readily available and unavailable.

The response plan should include a written plan outlining a clear process for gathering needed staff, operating room availability, staff roles and responsibilities, and performance of drills.

Risk management strategies to improve the timely availability of staff include:

• Define "readily available" and "immediately available" based on the needs of the community, geographic factors, and staffing levels. The definition should be in writing in organizational policy and medical staff bylaws. Compliance should be measured.
• Designate an on-call cesarean (OR) team and ensure the obstetric and the emergency departments have access to the information.
• Notify the cesarean (OR) team "when a complicated delivery is anticipated and when a patient with risk factors requiring a high-acuity level of care is admitted."³
• Consider the need for backup personnel for the on-call cesarean (OR) team and anesthesia provider. Trained obstetrical staff may be utilized to back up specific members of the cesarean (OR) team.

Develop a written plan to address how an expeditious emergency cesarean delivery will be performed when the cesarean (OR) team and the anesthesia provider are unavailable.

• This may occur during the day when all operating room staff and anesthesia providers are involved in other cases or during off-hours when the on-call cesarean (OR) team and anesthesia provider are involved with another emergency.

Include the following (at minimum) in the written plan:

• Develop an emergency cesarean "checklist."
• Require a sealed cesarean delivery kit or tray be available on the obstetric unit (also consider in the emergency department) or properly arranged on the instrument table in the operating room. Include a "checklist" for contents.
• Ensure medications required for emergency cesarean delivery are available, including local or regional anesthesia which could be administered by someone other than an anesthesia provider.
  • List these medications in the policy and ensure they are readily available on the unit in a specific area.
  • Obstetricians do not routinely perform local and regional anesthesia for cesarean deliveries; ensure they are trained, competent, and credentialed to perform these techniques.
• Identify roles for staff by function:
  • Nursing supervisor (e.g., procedure tray retrieval and set up, monitor the mother).
  • Labor and delivery nurse (e.g., patient prep, assist surgeon, monitor the fetus).
  • Support staff (e.g., calling a pediatrician, supporting family members).
  • Consider the use of code or rapid response team members.
• Ensure availability of emergency equipment for a potentially compromised newborn.
• Identify the designated area(s) where this procedure may occur (e.g., operating room, recovery room, obstetrical suite).
• Implement mock drills for these plans at least annually to assure all participants know their role, location of equipment, and expectations. Simulation drills and standardized procedures can decrease response times and positively affect outcomes.
  • Debrief the team after the drill.
  • Implement strategies based on lessons learned as appropriate.

Resources

^1,2,3 Guidelines for Perinatal Care, Eighth Edition.
American College of Obstetricians and Gynecologists: https://www.acog.org/