Delays in performing emergency caesarean sections at Harare maternity hospital and Mbuya Nehanda hospital: Causes and outcomes

Abstract

Introduction The ideal decision-to-delivery interval (DDI) for emergency Caesarean sections (ECS) quoted in international guidelines is 30minutes. Achieving this DDI is anticipated to improve perinatal outcomes. It has however been found in several institutions that it is not achievable in routine practice. There had not been a study in Zimbabwean institutions to determine our achieved DDI for ECS. In the event that we fail to achieve a 30minute DDI, there was no data on what were the influences or causes of delay in performance of ECS, and the maternal and perinatal outcomes thereof. Objective What is the achievable DDI for ECS performed at Harare Maternity Hospital (HMH) and Mbuya Nehanda Maternity Hospital (MNMH). What are the causes of delay in performing ECS and what are the perinatal and maternal outcomes. Design Hospital based prospective descriptive study. Setting Harare Maternity Hospital and Mbuya Nehanda Maternity Hospital Study population Consenting women that had undergone emergency Caesarean section. Methods Convenience sampling of women who had had ECS and were able to give consent to participate in the study was done. Data was collected by the researcher using a questionnaire on the day after they had ECS. On day 7 after the operation, a follow-up interview was conducted to check on the condition of both mother and baby. Data analysis was done using EPI INFO version 3.22 statistical software. Ethical approval was obtained from the ethics boards of each institution. Main outcomes of measure The indication of the ECS and the achieved DDI were explored. We also looked at the demographics and obstetric history of the participants, the stated causes of delayed DDI, the maternal morbidity and perinatal morbidity and mortality associated with delayed DDI. Results The total number of deliveries performed at both hospitals during the study period was 3 724 of which 1 050 (28.2%) were performed as Caesarean sections. Of all Caesarean sections, 866 were ECS (82.5%). The calculated sample size was 183. The study included 200 participants. The median age of participants was 25.5years. The majority of participants were married (94.5%), educated to secondary level or better (74%), Christian (68.5%), housewives (67.5%). 81 participants were primiparous. 13 participants delivered twins, therefore the total number of delivered infants was 213. Of these, 38 (17.8%) were delivered prematurely and 130 (16.9%) were term. 177 participants (88.5%) had booked their pregnancies. On admission, 147 (73.5%) were referred from within the Greater Harare Maternity Unit (GHMU), 26 (13%) were self-referrals and 27 (13.5%) were from outside the GHMU. The majority of participants had not had previous uterine surgery (75.5%). Most had successful regional anaesthesia (68%). In the study group, 92 participants (46%) had category 1 ECS and 108 (54%) had category 2 ECS. The median DDI for the whole group was 201.5minnutes (3hours 21minutes). Notably MNMH achieved a median DDI which was 1hour less than that at HMH. The top five causes of delay were delays in pre-operative preparation of the patient, theater being otherwise occupied, laboratory delays, delays in accessing blood products and delays in obtaining consent for theater. Of the 200 participants, only 14 (7%) had postpartum haemorrhage, and only 3 (1.5%) of these were still admitted 7days after the ECS while awaiting blood transfusion, the rest were home and in satisfactory condition. Of the 213 infants born, 186 (87.4%) had a 5minute Apgar of >7, 89 (41.8%) were admitted to neonatal unit and 27 (12.7%) suffered perinatal death.

Conclusion A 30 minute DDI is not achievable in our institutions but with minimal adverse effects on the parturient or her infant.