Decision to Incision and Risk for Fetal Acidemia, Low Apgar Scores, and Hypoxic Ischemic Encephalopathy

Objective This study aimed to assess risk for fetal acidemia, low Apgar scores, and hypoxic ischemic encephalopathy based on decision-to-incision time interval in the setting of emergency cesarean delivery. Study Design This unplanned secondary analysis of the Maternal-Fetal Medicine Units prospective observational cesarean registry dataset evaluated risk for hypoxic ischemic encephalopathy, umbilical cord pH <= 7.0, and Apgar score <= 4 at 5 minutes based on decision-to-incision time for emergency cesarean deliveries. Cesarean occurring for nonreassuring fetal heart rate monitoring, bleeding previa, nonreassuring antepartum testing, placental abruption, or cord prolapse was classified as emergent. Decision-to-incision time was categorized as <10 minutes, 10 to <20 minutes, 20 to <30 minutes, 30 to <50 minutes, or >= 50 minutes. As secondary outcomes umbilical cord pH <= 7.1, umbilical artery pH <= 7.0, and Apgar score <= 5 at 5 minutes were analyzed. Results Of 5,784 women included in the primary analysis, 12.4% had a decision-to-incision interval <= 10 minutes, 20.2% 11 to 20 minutes, 14.9% 21 to 30 minutes, 18.2% 31 to 50 minutes, and 16.5% >50 minutes. Risk for umbilical cord pH <= 7.0 was highest at <= 10 and 11 to 20 minutes (10.2 and 7.9%, respectively), and lowest at 21 to 30 minutes (3.9%), 31 to 50 minutes (3.9%), and >50 minutes (3.5%) (p < 0.01). Risk for Apgar scores <= 4 at 5 minutes was also higher with decision-to-incision intervals <= 10 and 11 to 20 minutes (4.3 and 4.4%, respectively) compared with intervals of 21 to 30 minutes (1.7%), 31 to 50 minutes (2.1%), and >50 minutes (2.0%) (p < 0.01). Hypoxic ischemic encephalopathy occurred in 1.5 and 1.0% of women with decision-to-incision intervals of <= 10 and 11 to 20 minutes compared with 0.3 and 0.5% for women with decision-to-incision intervals of 21 to 30 minutes and 31 to 50 minutes (p = 0.04). Risk for secondary outcomes was also higher with shorter decision-to-incision intervals. Conclusion Shorter decision-to-incision times were associated with increased risk for adverse outcomes in the setting of emergency cesarean.