Decision-to-incision time and neonatal outcomes: A systematic review and meta-analysis

OBJECTIVE:: To systematically review the literature on the proportion of emergent cesarean deliveries accomplished within 30 minutes, the mean time from decision-to-incision or delivery, and differences in neonatal outcomes in deliveries accomplished within 30 minutes compared to beyond 30 minutes. DATA SOURCES:: Electronic databases (Ovid MEDLINE and EMBASE and www.clinicaltrials. gov) were searched from inception to January 2013. METHODS OF STUDY SELECTION:: Eligible studies reported decision-to-incision time or delivery time intervals for nonelective cesarean deliveries. Both emergent and urgent deliveries (also known as category 1 and category 2 deliveries) were included. Two reviewers independently identified studies for inclusion. TABULATION, INTEGRATION, AND RESULTS:: Out of 737 reports identified in the primary search, 34 studies (22,936 women) met eligibility criteria. Seventy-nine percent (95% confidence interval [CI] 61-97%) of category 1 deliveries and 36% (95% CI 24-48%) of category 2 deliveries were achieved within 30 minutes, with significantly shorter time in category 1 compared to category 2 deliveries (21.2 compared with 42.6 minutes; P<.001). In the 13 studies that included neonatal outcomes, there was a higher risk of overall 5-minute Apgar score less than 7 (odds ratio [OR] 3.10; 95% CI 1.93-4.96) and umbilical artery pH level less than 7.10 (OR 3.40; 95% CI 2.38-4.87) in cases involving shorter delivery intervals. However, analyses limited to category 1 deliveries did not show a statistically greater risk of Apgar score less than 7 (OR 0.69; 95% CI 0.11-4.51) or umbilical artery pH level less than 7.10 (OR 1.10; 95% CI 0.28-4.40) with shorter delivery intervals. There was no difference by delivery interval in admission to neonatal intensive care units or special newborn units (OR 1.23; 95% CI 0.90-1.68). CONCLUSION:: Delivery within 30 minutes was not achieved in a substantial proportion of cases. The clinical significance of failing to achieve this standard remains uncertain.