ACOG: Decreasing Decision-to-Incision Times for Unscheduled, Urgent Cesarean Deliveries

Source: Tibavinsky Bernal, Lina MD; Yarrington, Christina D. MD; Xuan, Ziming ScD, SM; Zani, Lisa MSN, RN; Friedman, Scott RPh, JD; Schultz, Michele MSN, C-EFM; Chandra, Phanirekha MD; Iverson, Ronald E. MD, MPH. Decreasing Decision-to-Incision Times for Unscheduled, Urgent Cesarean Deliveries. Obstetrics & Gynecology 142(1):p 130-138, July 2023. | DOI: 10.1097/AOG.0000000000005221


To standardize the preprocedure process for urgent, unscheduled cesarean deliveries to decrease the time from decision to skin incision to improve maternal and fetal outcomes.


In our quality-improvement project, we selected indications that require urgent cesarean deliveries, created a standard algorithm, then implemented a multidisciplinary process intended to reduce decision-to-incision time. This initiative was conducted from May 2019 to May 2021, with a preimplementation period from May 2019 to November 2019 (n=199), implementation period from December 2019 to September 2020 (n=283), and postimplementation period from October 2020 to May 2021 (n=160). An interrupted time series calculation was performed, with stratification by patient race and ethnicity. The primary process measure was mean decision-to-incision time. The secondary outcomes were neonatal status as measured by 5-minute Apgar score and quantitative blood loss during the cesarean delivery.


We analyzed 642 urgent cesarean deliveries; 199 were preimplementation of the standard algorithm, and 160 were postimplementation. The mean decision-to-incision time improved from 88 minutes (95% CI 75–101 min) to 50 minutes (95% CI 47–53 min) from the preimplementation period to the postimplementation period. When stratified by race and ethnicity, the mean decision-to-incision time among Black non-Hispanic patients improved from 98 minutes (95% CI 73–123 min) to 50 minutes (95% CI 45–55 min) (t=3.27, P<.01); it improved from 84 minutes (95% CI 66–103 min) to 49 minutes (95% CI 44–55 min) among Hispanic patients (t=3.51, P<.001). There was no significant improvement in decision-to-incision time among patients in other racial and ethnic groups. When the cesarean delivery was performed for fetal indications, Apgar scores were significantly higher in the postimplementation period compared with the preimplementation period (8.5 vs 8.8 beta=0.29, P<.01).


Development and implementation of a standard algorithm to expedite decision-to-incision time for unscheduled, urgent cesarean deliveries led to a significant decrease in decision-to-incision time.