11/14/04njm

**Q.** What are some of the issues involving rapid cesarean delivery
[+]{.underline} local anesthesia?

**A**. It can be quite uncomfortable despite local infiltration. Think
about the surgical approach too.

1\. **What local agent would you use these days?**

"I would use lidocaine with epinephrine. Lidocaine with epinephrine can
be given up to 7mg/kg. Lidocaine without epinephrine can be given up to
5mg/kg. So epinephrine allows a higher dose and reduces bleeding and
probably quickens onset time."

2\. **How much can you use?**

"In a 70 kg person you could use 50ccs of 1% with epi, 100ccs of 0.5%
with epinephrine or 25ccs of 2% with epinephrine."

3\. **How long should you wait after each injection of successive
layers? **

The layers can be injected sequentially with no delay

**Other issues:**

Cesarean delivery with local anesthesia can still be very uncomfortable.
Low doses of ketamine 0.25 to 1.0 mg/kg IV might make for a more
tolerable situation. Someone would have to deal with the airway if
necessary and the dreaming/nightmares. Depending how stat the cesarean
delivery is needed, perhaps a spinal should be considered.

**Alternative Surgical approaches**

The Joel Cohen method is very fast. It includes several elements of
blunt extension of tissue planes and very few instruments. It is
described below

**Other resources online with some good references from our MCH web page
are:**

Cesarean Delivery

<http://www.uptodateonline.com/application/topic.asp?file=labordel/6548>

Anesthesia for cesarean delivery

<http://www.uptodateonline.com/application/topic.asp?file=labordel/9313&type=A&selectedTitle=3~75>

Principles of abdominal wall incisions

<http://www.uptodateonline.com/application/topic.asp?file=gyn_surg/10014>

**Rapid entry approaches and discussion of decision to incision times**

Joel-Cohen type cesarean delivery --- The Joel-Cohen technique is
similar to that of Pelosi, but with a few differences: the skin incision
is a straight transverse incision about an inch higher than the
Pfannenstiel incision, the subcutaneous tissues are incised for three
centimeters only in the midline and the defect extended laterally by
pulling with the index fingers, a bladder flap is made (but not closed),
the hysterotomy incision does not go all the way down to the amniotic
sac before the index fingers are used to open and extend it laterally,
and the hysterotomy is closed with interrupted sutures
\[[66,67](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=66~67&title=66,67)\].
Compared to the traditional procedure, this technique resulted in
reduced blood loss (250 versus 400 mL) and a shorter mean operating time
(20 versus 28 minutes) in one series
\[[66](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=66&title=66)\].
Similar findings were reported in other trials
\[[68-70](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=68~69~70&title=68-70)\].

Pelosi-type cesarean delivery --- A Pfannenstiel incision is made with a
knife and the subcutaneous tissues divided with an electrocautery
device. The fascia is opened transversely by electrocautery. The rectus
muscles are bluntly separated to create a space and then both index
fingers are inserted into this space to free the fascia cephalocaudally
and transversely. The peritoneum is then perforated using an index
finger, if possible, and both hands are used to stretch the full
thickness abdominal wall (skin, subcutaneous tissue, fascia, muscles,
peritoneum) to the full size of the skin incision ([show picture
1](http://www.uptodateonline.com/application/image.asp?file=obst_pix/pelosi_a.gif)).
The peritoneal incision may be extended with electrocautery, if
required.

A traditional bladder flap is not performed; this appears to decrease
operating time, blood loss, and need for postoperative analgesia
\[[64](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=64&title=64)\].
A 1 cm transverse incision is made in the lower uterine segment to, but
not through, the amniotic sac. This incision is extended laterally and
slightly cephalad in both directions by pulling with the index fingers
or by cutting with bandage scissors if the myometrium is thick ([show
picture
2](http://www.uptodateonline.com/application/image.asp?file=obst_pix/selfreta.gif)).

The fetus is then delivered by lifting the presenting part out of the
hysterotomy and applying transabdominal fundal pressure ([show picture
3](http://www.uptodateonline.com/application/image.asp?file=obst_pix/delive4.gif)).
If this is difficult, a soft vacuum cup can be applied to the vertex and
the fetus extracted. The placenta is removed after awaiting spontaneous
separation. The uterus is massaged and
[oxytocin](http://www.uptodateonline.com/application/topic.asp?file=drug_l_z/190133&drug=true)
(20 units/L) administered to control uterine bleeding.

The uterus is then closed in one layer with a continuous locking
0-chromic suture ([show picture
4](http://www.uptodateonline.com/application/image.asp?file=obst_pix/closur10.gif)).
The visceral and parietal peritoneum are not closed. The fascia is
reapproximated with a continuous nonlocking synthetic absorbable suture
and the skin reapproximated with staples. The subcutaneous fat layer is
not sutured unless the patient is markedly obese, in which case a few
interrupted 3-0 absorbable sutures are placed to obliterate the dead
space.

In one study that compared 101 Pelosi-type cesarean deliveries to the
traditional technique (174 deliveries), the Pelosi procedure resulted in
significantly decreased operative time (27 versus 45 minutes), blood
loss (postoperative hemoglobin 10.5 versus 10.2 g/dL), and overall cost
(\$7623 versus \$8613)
\[[65](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=65&title=65)\].
There was also a trend toward a reduction in postoperative fever (2
versus 10 percent).

EMERGENCY CESAREAN DELIVERY --- The American College of Obstetricians
and Gynecologists has maintained that a facility providing obstetric
services should be capable of beginning an emergency cesarean delivery
within 30 minutes of the decision to perform the operation
\[[18](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=18&title=18)\].
This criterion is based upon the practical constraints most rural
hospitals face in assembling the appropriate team of nurses,
anesthetists, and surgeons. However, this threshold is not
evidence-based, universally achievable, or ideal, from the perspective
of decreasing perinatal mortality and morbidity
\[[19-25](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=19~20~21~22~23~24~25&title=19-25)\].

Audits of deliveries from two areas of England found that the 30 minute
goal was achieved in only two of three deliveries, and questioned the
utility of this standard
\[[21,22](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=21~22&title=21,22)\],
which was based on expert opinion (level III evidence). A subsequent
national cross sectional survey of maternity units in England and Wales
found that the 30 minute goal was achieved in 46 percent of deliveries
deemed to have an \"immediate threat to life of the woman or fetus\" and
only 22 percent of all emergency cesarean births
\[[25](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=25&title=25)\].
The difficulty in achieving the 30 minute goal was confirmed by a
literature review that reported a decision to delivery interval of
![](media/image1.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}30 minutes was achieved in only 52 to 78
percent patients
\[[21](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=21&title=21)\].

The ability to begin an emergency cesarean delivery within 30 minutes of
the decision to operate is a reasonable benchmark for monitoring the
quality of labor and delivery units. However, sudden complete anoxia,
such as occurs with a total abruption or complete cord occlusion,
probably necessitates delivery within five minutes to avoid fetal
hypoxic injury
\[[26](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=26&title=26)\],
although intact survivors have been reported after longer durations of
severe hypoxia. Most pregnancies with less severe fetal or maternal
compromise will have good outcomes despite longer intervals before
initiating surgery. For example, one study showed the average times to
acidosis associated with late and variable decelerations in a term fetus
with an initially normal tracing were 115 and 145 minutes, respectively
\[[27](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=27&title=27)\].
The national survey discussed above found that babies delivered within
15 minutes of the decision to operate had similar outcomes to those
delivered within 16 to 75 minutes; however, there was an increased risk
of Apgars \<7 at five minutes after a 75 minute interval
\[[25](http://www.uptodateonline.com/application/abstract.asp?TR=labordel/6548&viewAbs=25&title=25)\].

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  19 - James, D. Caesarean section for fetal distress. BMJ 2001;
  322:1316.

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no abstract available.

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  20

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TI - The decision-to-delivery interval for emergency caesarean section:
is 30 minutes a realistic target?\
AU - Helmy WH; Jolaoso AS; Ifaturoti OO; Afify SA; Jones MH\
SO - BJOG 2002 May;109(5):505-8.\
\
OBJECTIVE: To evaluate whether a 30-minute decision-to-delivery interval
is a realistic target for emergency caesarean section. DESIGN: An audit
of all emergency caesarean sections over five separate periods. SETTING:
A district general hospital. PARTICIPANTS: Five groups of women (343
women) with an indication for emergency caesarean section. METHODS:
Following an initial survey, a structured time sheet was introduced,
followed by four other surveys to complete the audit cycle. MAIN OUTCOME
MEASURE: The proportion of caesarean sections where the
decision-to-delivery interval was achieved within 30 minutes. The
reasons for delay. RESULTS: In the first survey of 73 emergency
caesarean sections, the time to deliver the infant exceeded 30 minutes
in 47 women (64%). The main sources of delay were transferring the women
to the operating theatre and starting the anaesthetic. After the
introduction of a structured time sheet, there was an improvement with
each survey, but the target of 30 minutes was reached in only 71% of
caesarean sections in the final survey. CONCLUSIONS: The introduction of
a time sheet can improve the decision-to-delivery interval for emergency
caesarean section; however, a universal standard of 100% in 30 minutes
is unrealistic.\
\
AD - Department of Obstetrics, Gravesend and North Kent Hospital, UK.\
PMID- 12066938

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TI - Interval between decision and delivery by caesarean section-are
current standards achievable? Observational case series.\
AU - Tuffnell DJ; Wilkinson K; Beresford N\
SO - BMJ 2001 Jun 2;322(7298):1330-3.\
\
OBJECTIVES: To audit interval from decision to delivery in urgent
caesarean section to determine whether the current standard of 30
minutes is achievable routinely; to determine whether delay leads to an
excess of admissions to special care. DESIGN: Three audit cycles over
four years followed by a continuous audit over 32 months. SETTING: Large
district general hospital delivering 5500 women each year. PARTICIPANTS:
All women delivered by urgent caesarean section for abnormal fetal heart
rate patterns, cord prolapse, failed instrumental delivery, or suspected
placental abruption. MAIN OUTCOME MEASURES: Proportion of women
delivered within 30 and 40 minutes of decision. Admission rates to
special care by length of interval between decision and delivery.
RESULTS: In the continuous audit 478 of 721 (66.3%) women were delivered
in 30 minutes and 637 (88.3%) within 40 minutes; 29 (4.0%) were
undelivered at 50 minutes. If the woman was taken to theatre in 10
minutes, 409 of 500 (81.8%) were delivered in 30 minutes and 495 (97%)
in 40 minutes. There was no significant difference in the proportion of
babies born at 36 weeks or later who were admitted to special care, when
analysed by interval from decision to delivery. 36/449 (8%) babies with
an interval from decision to delivery of less than 30 minutes were
admitted to special care and 3/23 (13%) with an interval of more than 50
minutes were admitted. CONCLUSIONS: The current recommendations for the
interval between decision and delivery are not being achieved in routine
practice. Failure to meet the recommendations does not seem to increase
neonatal morbidity.\
\
AD - Maternity Unit, Bradford NHS Trust, Bradford BD9 6RJ.
derek.tuffnell@bradfordhospitals.nhs.uk\
PMID- 11387177

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TI - Prospective 12 month study of 30 minute decision to delivery
intervals for \"emergency\" caesarean section.\
AU - MacKenzie IZ; Cooke I\
SO - BMJ 2001 Jun 2;322(7298):1334-5.\
\
AD - Nuffield Department of Obstetrics and Gynaecology, University of
Oxford, John Radcliffe Hospital, Oxford OX3 9DU.\
PMID- 11387178

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TI - Cesarean section for suspected fetal distress. Does the
decision-incision time make a difference?\
AU - Chauhan SP; Roach H; Naef RW 2nd; Magann EF; Morrison JC; Martin JN
Jr\
SO - J Reprod Med 1997 Jun;42(6):347-52.\
\
OBJECTIVE: To compare perinatal outcomes in patients at term (37 weeks)
in whom the decision-incision time for cesarean delivery was due to
suspected fetal distress. STUDY DESIGN: All parturients who underwent
cesarean delivery primarily for possible fetal distress during a
three-year period were identified retrospectively. Student\'s t test and
the chi 2 test were utilized, and P \< .05 was considered significant. A
regression analysis of decision-incision time and umbilical arterial pH
was performed. RESULTS: From 1991 to 1993, 1.3% (117/9,137) of term
laboring patients underwent emergency cesarean delivery for the primary
indication of possible fetal distress. In 61 patients (52%) the
decision-incision time was 30 minutes, while it exceeded 30 minutes in
the remaining 56 women. The two patient groups were similar in maternal
demographics, antepartum complications, oxytocin usage, thick meconium,
type of abnormal fetal heart rate tracing prompting surgery, use of
amnioinfusion (41% vs. 36%), general anesthesia (97% vs. 93%), mean
birth weight and Apgar score \< 7 at five minutes. Three adverse
outcomes were observed more frequently in association with
decision-incision time \> 30 minutes: (1) lower mean (+/-SD) umbilical
arterial pH (7.16 +/- 0.15 vs. 7.26 +/- 0.06, P = .001), (2) pH \< 7.00
(8/61 vs. 0/56, P = .005), and (3) admission to the neonatal intensive
care unit (P = .008). When the incision was made longer than 30 minutes
after the decision, there was no apparent adverse neonatal or infant
outcome. CONCLUSION: Although a cesarean decision-incision time \< or =
30 minutes is a desirable goal for the fetus possibly in distress,
failure to achieve this goal is not associated with a measurable
negative impact on newborn outcome.\
\
AD - Department of Obstetrics and Gynecology, University of Mississippi
Medical Center, Jackson, USA.\
PMID- 9219122

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TI - What is a reasonable time from decision-to-delivery by caesarean
section? Evidence from 415 deliveries.\
AU - MacKenzie IZ; Cooke I\
SO - BJOG 2002 May;109(5):498-504.\
\
OBJECTIVE: To determine how long it takes from the decision to achieve
delivery by non-elective caesarean section (DDI), the influences on this
interval, and the impact on neonatal condition at birth. DESIGN: Twelve
months prospective data collection on all non-elective caesarean
sections. METHODS: Prospective collection of data relating to all
caesarean sections in 1996 in a major teaching hospital obstetric unit
was conducted, without the knowledge of the other clinicians providing
clinical care. Details of the indication for section, the day and time
of the decision and the interval till delivery were recorded as well as
the seniority of the surgeon, and condition of the baby at birth.
RESULTS: The mean time from decision-to-delivery for 100 emergency
intrapartum caesarean sections was 42.9 minutes for fetal distress and
71.1 minutes for 230 without fetal distress (P \< 0.0001). For 22
\'crash\' sections the mean time from decision-to-delivery was 27.4
minutes; for 13 urgent antepartum deliveries for fetal reasons it was
124.7 minutes and for 21 with maternal reasons it was 97.4 minutes. The
seniority of the surgeon managing the patient did not appear to
influence the interval, nor did the time of day or day of the week when
the delivery occurred. Intrapartum sections were quicker the more
advanced the labour, and general anaesthesia was associated with shorter
intervals than regional anaesthesia for emergency caesarean section for
fetal distress (P \< 0.001). Babies born within one hour of the decision
tended to be more acidaemic than those born later, irrespective of the
indication for delivery. Babies tended to be in better condition when a
time from decision-to-delivery was not recorded than those for whom the
information had been recorded. CONCLUSION: Fewer than 40% intrapartum
deliveries by caesarean section for fetal distress were achieved within
30 minutes of the decision, despite that being the unit standard. There
was, however, no evidence to indicate that overall an interval up to 120
minutes was detrimental to the neonate unless the delivery was a
\'crash\' caesarean section. These data thus do not provide evidence to
sustain the recommendation of a standard of 30 minutes for intrapartum
delivery by caesarean section.\
\
AD - Nuffield Department of Obstetrics and Gynaecology, University of
Oxford, John Radcliffe Hospital, UK.\
PMID- 12066937

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TI - National cross sectional survey to determine whether the decision
to delivery interval is critical in emergency caesarean section.\
AU - Thomas J; Paranjothy S; James D\
SO - BMJ 2004 Mar 20;328(7441):665. Epub 2004 Mar 15.\
\
OBJECTIVE: To examine the association between decision to delivery
interval and maternal and baby outcomes. DESIGN: National cross
sectional survey. SETTING: Maternity units in England and Wales.
SUBJECTS REVIEWED: 17 780 singleton births (99% of all births) delivered
by emergency caesarean section in England and Wales between 1 May 2000
and 31 July 2000. MAIN OUTCOME MEASURES: Association between decision to
delivery interval and baby outcomes (Apgar scores of \< 7 and \< 4 at
five minutes and stillbirth) and maternal outcomes (requirement for
special care additional to routine care after caesarean section and
where care was provided). RESULTS: Compared with babies delivered within
15 minutes, there was no difference in maternal or baby outcome for
decision to delivery interval between 16 and 75 minutes. After 75
minutes, however, there was a significantly higher odds of a five minute
Apgar score of \< 7 (odds ratio 1.7, 95% confidence interval 1.2 to
2.4), and 50% increase in odds of special care additional to routine
care for mothers. CONCLUSION: A decision to delivery interval of 30
minutes is not an absolute threshold for influencing baby outcome.
Decision to delivery intervals of more than 75 minutes are associated
with poorer maternal and baby outcomes and should be avoided.\
\
AD - National Collaborating Centre for Women\'s and Children\'s Health,
London NW1 4RG. JThomas@rcog.org.uk\
PMID- 15023829