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Volume 5, No. 11, December 2007
Abstract of the Month
30 minute rule not a requirement and ‘immediately available’ defined locally
Stanley Zinberg, M.D., ACOG Deputy Executive Vice President published comments recently on the background and meaning of the so called ’30 minute rule’. Dr. Zinberg references the 2006 National Institute of Child Health and Human Development (NICHD) article by Bloom SL et al (below) and the subsequent letters to the editor.
The NICHD results found that in the great majority of cases, providers effectively triage emergency cesarean deliveries when given the capability to begin the operation within 30 minutes, which is what was intended when the ACOG / AAP guideline was promulgated. In addition, approximately one third of primary cesarean deliveries performed for emergency indications are commenced more than 30 minutes after the decision to operate, and the majority were for nonreassuring heart rate tracings. In these cases, adverse neonatal outcomes were not increased.
The required personnel should be in the hospital, or immediately available, to perform emergency cesarean delivery. The immediately available phrase was intended to be a guideline that could be implemented nationally, including in rural settings. ACOG recognizes that each institution should define “immediately available” based on its resources and geographic location.
The ACOG / AAP guideline on emergency cesarean delivery does not establish the 30-minute interval to be a requirement that all cesarean deliveries must be performed within 30 minutes of the decision. The recent NICHD data found that most infants delivered for emergency indications were not compromised, whether delivered less than or more than 30 minutes from the decision to operate.
Decision-to-incision times and maternal and infant outcomes
OBJECTIVE: To measure decision-to-incision intervals and related maternal and neonatal outcomes in a cohort of women undergoing emergency cesarean deliveries at multiple university-based hospitals comprising the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. METHODS: All women undergoing a primary cesarean delivery at a Network center during a 2-year time span were prospectively ascertained. Emergency procedures were defined as those performed for umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, nonreassuring fetal heart rate pattern, or uterine rupture. Detailed information regarding maternal and neonatal outcomes, including the interval from the decision time to perform cesarean delivery to the actual skin incision, was collected. RESULTS: Of the 11,481 primary cesarean deliveries, 2,808 were performed for an emergency indication. Of these, 1,814 (65%) began within 30 minutes of the decision to operate. Maternal complication rates, including endometritis, wound infection, and operative injury, were not related to the decision-to-incision interval. Measures of newborn compromise including umbilical artery pH less than 7 and intubation in the delivery room were significantly greater when the cesarean delivery was commenced within 30 minutes, likely attesting to the need for expedited delivery. Of the infants with indications for an emergency cesarean delivery who were delivered more than 30 minutes after the decision to operate, 95% did not experience a measure of newborn compromise. CONCLUSION: Approximately one third of primary cesarean deliveries performed for emergency indications are commenced more than 30 minutes after the decision to operate, and the majority were for nonreassuring heart rate tracings. In these cases, adverse neonatal outcomes were not increased. LEVEL OF EVIDENCE: II-2.
Bloom SL, et al Decision-to-incision times and maternal and infant outcomes. Obstet Gynecol. 2006 Jul;108(1):6-11.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16816049
OB/GYN CCC Editorial comment:
The Rule of Parley was really more of a ‘guideline’
I assume most of you have seen the first of the three Pirates of the Caribbean films, the 2003 Walt Disney film Curse of the Black Pearl. If not, at one point Elizabeth Swann (Keira Knightley) daughter of the Port Royal, Jamaica Governor, Weatherby Swann, finds herself captured by pirates.
After her capture Ms Swann invokes the ‘Rule of Parley’—an agreement ensuring one's safety until meeting and negotiating with the opposing side – when she is presented to the pirate Captain Hector Barbossa (Geoffrey Rush) on the deck of the Black Pearl. Captain Barbossa initially agrees not to harm his new prisoner, but in one of the better lines in the movie he seeks to clarify that “the Rule of Parley is really more of a guideline.” when it comes to the actual details of implementation.
This classic line* intimates that institutionalized ‘double speak’ may have been with us for centuries, and not invented during the recent era of Dilbert like office cubicles. Though we can all empathize with Ms. Swann’s predicament, in much the same way some institutions and providers have misconstrued ACOG’s efforts.
ACOG has sought to educate its members, other providers, and their facilities that a prompt systematic response needs to be immediately available when intrapartum, or other obstetric emergencies, arise. The 30 minute rule is not a requirement, it really more of a guiding principle for appropriate prompt action.
In those cases of successful intrauterine resuscitation, a longer interval, or no cesarean delivery at all, may be appropriate, though all the necessary resources were on standby in the interim.
The ‘17 minute rule’
In some cases, the clinical situation may require an immediate delivery, or more precisely a delivery within 17 minutes.
One study looking at this question comes from U.S.C.- Los Angeles County Medical Center, where, until the recent past, over 15,000 deliveries a year were attended, the majority occurring to women recently immigrated from Mexico with very little in the way of past obstetric records. Leung et al reported in October 1993 that the clinical signs of actual uterine rupture were not those classically described in the textbooks. Excessive pain and vaginal bleeding were seen in less than 15% of the cases, loss of the uterine pressure tracing in none, and recession of the presenting part in only 6%.
All the infants that died were extruded from the uterus into the abdominal cavity, and--of special clinical significance--all the deaths, and all the neurologic injuries, occurred if the time from suspicion of rupture to delivery exceeded 17 minutes .
Periodic drills
In any case, each institution should perform periodic drills to streamline their maternity team’s prompt response to obstetric emergencies. A stellar example of obstetric emergency drills is available at Phoenix Indian Medical Center (PIMC).
Inspired by Dr. Michelle Lauria’s presentation at the 2004 Native Women’s Health and MCH Conference entitled ‘Emergency Delivery Simulations: How to Develop Teamwork’, PIMC began a successful organized approach to obstetric emergencies. The PIMC experience with emergency drills was subsequently reported at the 2007 version of the same conference by Karen Carey CNM and Tami McBride CNM MS.
30 minute rule is not a requirement. ACOG Today
October 2007 page 2
ACOG Members
http://www.acog.org/publications/acog_newsletters/acogToday1007.pdf
Non ACOG Members
Emergency Delivery Simulations: How to Develop Teamwork , Dr. Michele Laura
http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt
Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 54. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;104:203–12 .
Other
Schauberger CW. Decision-to-incision times and maternal and infant outcomes. Obstet Gynecol. 2006 Nov;108(5):1298; author reply 1298
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17077260
Dupuis O. Decision-to-incision times and maternal and infant outcomes.Obstet Gynecol. 2006 Nov;108(5):1297-8; author reply 1298.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17077258
Katz VL. Cesarean birth: guidelines, not rules. Obstet Gynecol. 2006 Jul;108(1):2-3.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16816047
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
