Decision to Delivery Interval in Emergency Cesarean Section at Two Academic Hospitals in Yogyakarta and Central Java, Indonesia

Decision to Delivery Interval in Emergency Cesarean Section at Two Academic Hospitals in Yogyakarta and Central Java, Indonesia Shinta Prawitasari1, Doni Widyandana2, Mohammad Hakimi1, Adi Utarini3* Background: The international guideline suggests that the ideal DDI is 30 minutes for grade 1 and grade 2 CS, but they are still hardly achieved. Therefore, the main purpose of this study was to determine the DDI for grade 1 and 2 CS, and its determinants in two academic hospitals. Methods: A prospective cohort study was conducted using pregnant women who underwent grade 1 and 2 emergency CS. Data regarding demographic characteristics of the subjects were extracted from the medical record, while DDI and its components were measured by direct observation. Odds ratio was used to determine the association between DDI and its


INTRODUCTION
Cesarean Section (CS) has a huge potential to reduce maternal and perinatal deaths up to 72%, 1 especially in emergency cases with indications such as hemorrhage from placenta previa, placental abruption, umbilical cord prolapse, or uterine rupture. 2 The moment between a decision to delivery time is very crucial because it can be an imminent threat for mother, baby, or both life. 3, 4 The Decision to Delivery Interval (DDI), defined as the interval in minutes between the decision by obstetrician and time to deliver the baby, is important to measure quality of care, mainly in grade 1 and grade 2 CS where there are chances of life-threatening conditions. 4 According to the international guidelines from The National Institute of Clinical Excellence (NICE) UK, and The American College of Obstetrician and Gynecologist (ACOG), a 30 minute DDI should be applied for grade 1 and grade 2 CS with an extension up to 75 minutes for grade 2. 1, 5 Previous large cohort studies in developed countries found that only twothirds of all primary CS were delivered within 30 minutes. 2 Another large national cross sectional survey across UK found 63% of units had 50% of DDI within 30 minutes for grade 1 CS. 1 The reasons for delayed DDI were impaired inter-professional collaboration in preparing CS, lack of personnel, and lack of appropriate facilities. 5, 6 In conditions where DDI within 30 minutes could not be accomplished, undesirable outcome is unavoidable if the delay continues beyond 75 minutes. 4 Thomas et al. found that DDI >75 minutes was associated with 80% increased odds of a five minute APGAR score of < 7 (1.8, 1.3 to 2.4) and 50% increase in the odds of special care admittance for mothers. 1 In developing countries, the data from several studies showed that the average DDI are still lagging, with interval between 100-180 minutes. 7 Indonesia as one of the developing countries in South-East Asia is also struggled to achieve the standards. 8 This problem was evident even in hospitals with high resources, such as the academic hospitals. Despite having parity, patient status, baby's birth weight were collected from the hospital medical birth registry and medical records. Other determinants of DDI such as the location of care, grade and indication of CS and time of CS, as well as the perinatal team response time, anesthesiologist response time, transport time, emergency operating room waiting time, and anesthesiologist preparation time were all collected prospectively using direct observation conducted by trained research assistants. DDI was measured as the interval in minutes between time of the decision by the obstetrician to the delivery of the baby. In the analysis, we used continuous and dichotomous data which were grouped into less or equal to and more than 75 minutes based on the previous study by Thomas et al. 1 Perinatal team response time (minutes) was defined as the interval between patient arrival and perinatal team arrival at the emergency operating rooms, categorized into less or equal and more than 15 minutes according to existing practice in both academic hospitals. The anesthesiologist response time was the interval in minutes between the notifications to the approval of the anesthesiologist consultant for the time of surgery, and it was categorized into less or equal and more than 20 minutes. Transport time was defined as the interval in minutes between the approval of the anesthesiologist and patient arrival to the emergency operating room and was categorized into less or equal and more than 10 minutes; Meanwhile, operating room waiting time was measure in minutes between patient arrival to the emergency operating theatre to the patient arrival at the operating room and was categorized into less or equal and more than 10 minutes. Finally, anesthesiologist preparation time was defined as the interval in minutes from patient arrival at the operating room to successful anesthetic induction which was also categorized into less or equal and more than 10 minutes. All of these variables were recorded as dichotomous variables as in studies by Gupta et al. and Hirani et al. 5,9 Data analysis Normality of data distribution was assessed and data analysis was carried out using Statistical Package for Social Science (SPSS) software version 22 from IBM. Descriptive statistics were summarized using frequency and proportions for dichotomous variables. Median interquartile range was used to calculate DDI because data were not distributed normally. The odds ratio was used to determine the associations between DDI and subject demographic characteristics such as age, gestational age, parity, patient status, location of care, diagnosis for the CS, DDI based on CS urgency, indications, time of SC and baby's birth weight. The odds ratio was also calculated to evaluate the relationship between perinatal team response time, anesthesiologist response time, transport time, operating room waiting time, and anesthesiologist preparation and DDI. A p-value < 0.05 was considered statistically significant.

Characteristics of the study participants
There were 77 and 71 pregnant women in the main hospital and the affiliated hospital who underwent CS grade 1 and grade 2 during the study period. The percentage of grade 1 CS out of all C sections performed during the study period in the main hospital was 49% and grade 2 CS was 28%. The percentage of grade 1 CS in the affiliated hospital was 51% and for grade 2 CS was 20% respectively. The subject's demographic characteristics such as age (OR: 0.42; 95%CI: 0.11-1.51), gestational age (OR: 0.94; 95%CI: 0.27-3.28), patient status (referred or inpatient) (OR: 0.32 95%CI: 0.08-1.30), parity (OR: 2.22; 95%CI: 0.44 -11.08) and baby's birth weight (OR: 1.14; 95%CI: 0.32-3.99) had no significant influence in achieving DDI within 75 minutes or more at the main and affiliated hospitals ( Table 1).

Indications of Cesarean Section
A 30-minute standard of DDI was only achieved in 1.41% of grade 1 CS in the affiliated academic hospital, while none was achieved in the main academic hospital (data not shown).
Applying the 75 minute cut off point, 22.4% and 51% of grade 1 CS and 3.6% and 35% of grade 2 CS met the standard better facilities and human resources compared to the non-academic hospitals, 6 those challenges remain, especially in interprofessional collaboration. Therefore, this study was carried out to determine the DDI for grade 1 and 2 emergency CS and to measure its determinants in academic hospital settings.

Study setting
The study was conducted in two academic tertiary hospitals of the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, i.e. one main academic and one affiliated academic hospitals, located in the Southern part of Central Java province. The main academic hospital is equipped with 25 obstetricians, 15 anesthesiologists, 4 neonatologists, with 44 obstetrics residents placed in the emergency department during the study period. In 2019, 990 deliveries were recorded with 48.60% CS rate. Two emergency operating rooms were available for various emergency cases, including CS. In comparison, the affiliated academic hospital has only 5 obstetricians, 5 anesthesiologists, 1 neonatologist, and 33 obstetrics residents performing 1,567 deliveries with 33.70% CS rate in 2019. Only one emergency operating room was available for all types of emergencies. In both hospitals, the emergency operating rooms were located in separate buildings to the delivery room.

Study design and subjects
This study used a prospective cohort design and using pregnant women who underwent emergency CS grade 1 and 2 as the subjects. The criteria for grade 1 and 2 CS were taken from Thomas

DISCUSSION
The main purpose of this study was to determine the DDI for grade 1 and grade 2 emergency CS, and the determinants in main and affiliated academic hospitals. Overall, very few grade 1 CS surgery was carried out within 30 minutes of DDI. If a longer cut off point was applied, 22.4% and 51% of grade 1 CS in two academic hospitals met the criteria within 75 minutes.
The affiliated hospital had

Indication The Main Hospital (n 77) The Affiliated Hospital (n 71) n (%) Median DDI (minutes) (IQR) n (%) Median DDI (minutes) (IQR)
Imminent minutes were only achieved in 1.8% of cases. However, the DDI for grade 1 and grade 2 in both academic hospitals in Indonesia was better than their study, 10 albeit lower than in other developing countries such as in India and Tanzania. 5,9,10 Although a 30 minute standard DDI did not significantly influence the delivery outcome, DDI of more than 75 minutes was associated with a poorer neonatal outcome and increased admission rate to special care institution for the mother. 1, 10 Both academic hospitals in this study were tertiary hospitals with different volume of total deliveries annually. The main hospital had a smaller number of total deliveries but with higher CS rate compared to the affiliated hospital. The DDI in the affiliated hospital was better than the main hospital. This study was contrary to Kolas et al. which found that DDI was longer in a level 3 hospital (with more than 1,500 annual deliveries) than level 2 hospital (with 400-1500 annual deliveries). 11 Better interprofessional collaboration in preparing the emergency CS in the affiliated hospital might become the reason. 6,10,11, 12 Grade 1 CS significantly became the determinants for DDI within 75 minutes in the main hospital. According to the international guideline, DDI for Grade 1 CS should be accomplished within 30 minutes. 1 The median DDI for grade 1 CS in the main hospital was 112.50 minutes. Even though we had not been able to fulfill the standard yet, the awareness was already developed and would become a strength for further improvement.
Fetal distress was a significant determinant for DDI in the main hospital. The finding was similar to studies undertaken by Owalabi et al., Temesgen et al. and Kolas et al. 11,13,14 The indication of CS significantly influenced the DDI. 11 CS for fetal-related factors, such as fetal distress and cord prolapse, shortened the DDI in both academic hospitals. The median DDI for maternal indication such as severe antepartum bleeding as the indication for grade 1 CS were significantly longer which might be caused by stabilization required prior to CS. In Hirani et al. and Kolas et al., hypertension during pregnancy significantly increased the DDI. 9, 11 Finally, anesthesiologist response time significantly influenced DDI within 75 minutes or more in the main hospital. More than 90% of prolonged anesthesiologist response time (>20 minutes) occurred in CS with DDI more than 75 minutes in the main hospital. Likewise, Rhadakhrisnan et al. and Gupta et al. discovered that interval between decision to do CS to moving the patient to operating theatre (which includes anesthesiologist response time in our study) become the most responsible factor for prolonged DDI in grade 1 and grade 2 CS. 5,10 It was also included in decision to operating room interval in Khemworapong et al. study. 12 Two reasons documented in our study for delayed anesthesiologist response time were the anesthesiologist being busy with another emergency patient and waiting time required for patient stabilization. In Rhadakhrisnan et al. study, 15% of the delay was inevitable because of the need to do resuscitation before anesthesia induction, and 78% of them were grade 1 and 2 CS. 10 In the affiliated academic hospital, none of the above factors were significant. Operating room waiting time was the only significant determinants for DDI within 75 minutes or more. The availability of only one operating room in this ORIGINAL ARTICLE  16 Sutcliffe et al. further found that conflicting roles and role ambiguity, interpersonal power and conflict might also interfere the communication between residents and other health professionals. 16 Previous study suggested that the ability of the obstetrician to communicate the urgency of the CS and remind the passage of time to the anesthesiologists and the rest of the team was essential to improve DDI. 6 Another study by Le Mitouard et al. used the color code protocol to improve the DDI for grade 1 and grade 2 CS in an academic hospital in Lyon, France. With this protocol, effective communication between the interprofessional team was improved and the DDI was significantly shorter. 17 Several interventions such as automated call-outs, implementing standard operating procedures, and staff training using crew resource management techniques might be used to prevent delays in care of acutely ill patients. 18 Standard operating procedure for grade 1 and grade 2 CS preparation with interprofessional collaboration approach should be implemented strictly in the main and affiliated hospital.
There were several limitations in this study such as limited data on the reasons behind delays in each interval processes that contributed to DDI of grade 1 and grade 2 CS in both hospitals. There was also no recorded data about the ratio of pregnant women and midwives during the CS preparation which may contribute to the delayed DDI as well. Detailed recording on barriers for every process interval (anesthesiologist response time, perinatal team response time, transport time, operating room waiting time, and anesthesiologist preparation) and the availability of human resources during CS preparation would give valuable insights on how to evaluate the implementation of existing standard operating procedure for emergency CS grade 1 and grade 2. Nonetheless the existing data was valuable enough for better understanding of the delayed DDI in this study

CONCLUSION
The Decision to Delivery Interval (DDI) in both academic hospitals were still below the international standard in most of the CSs. The critical factor in the main academic hospital was the anesthesiologist response time delay, while the affiliated academic hospital should overcome delay due to availability of the operating room. Quality improvement studies are needed to find the most effective approaches to reduce the DDI in emergency CS in the academic hospital setting.

AUTHOR CONTRIBUTION
All authors have contributed to all processes in this research, including preparation, data gathering, and analysis, drafting, and approval for publication of this manuscript.