"Let everyone know we're crashing room 10 now!!" If you are a labor nurse, you've probably heard something similar recently. Emergent or urgent cesarean birth occurs commonly in busy labor units. As soon as the decision is made, all members of the surgical team should be notified so immediate preparations can begin. Hospitals that offer perinatal services should be able to perform an emergent cesarean birth within 30 minutes of the decision to do so (American Academy of Pediatrics [AAP] & American College of Obstetricians and Gynecologists [ACOG], 2002). However, some clinical situations, such as hemorrhage from placenta previa or placental abruption, umbilical cord prolapse, and uterine rupture, require more expeditious birth because they can directly or indirectly cause fetal death or other adverse outcomes (AAP & ACOG, 2002). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2004) recommends periodic emergent cesarean birth drills. A recent study found that interdisciplinary team training was associated with a shorter decision-to-incision time (33.3 minutes vs. 21.2 minutes) compared to hospitals that did not participate in team training (Nielsen et al., 2007).
Whenever possible, a surgical suite should be kept available for emergent cases. If this is not possible, at a minimum, elective or non-emergent cases should be staggered to allow rapid room readiness if an emergency occurs. There should be plans for calling in back-up team members when members who are primarily responsible for obstetrical emergencies are occupied with other procedures that would preclude their immediate availability. Access to direct phone numbers, including cellular phones, of individuals on call is more likely to result in faster communication than beepers. If a physician is notified of a situation that is likely to require an emergent cesarean birth while not in house and he or she orders preparations for surgery, hospital policy should allow preparations to begin before the physician's arrival. Policies that require the physician to be in house to order cesarean birth can result in unnecessary delays and potentially contribute to an adverse outcome.
Approximately 1.1% of babies born via cesarean suffer injuries, such as skin laceration, abrasion, bruising, subconjunctival hemorrhage, cephalohematoma, clavicular fracture, facial nerve injury, brachial plexus injury, skull fracture, long bone fracture, and intracranial hemorrhage (Alexander et al., 2006). Babies born less than 5 minutes after the incision time have a higher injury rate than babies born more than 5 minutes after the incision time (Alexander et al., 2006). Cesarean birth after failed forceps or vacuum attempt has the highest risk of fetal injury, followed by nonreassuring fetal status (Alexander et al., 2006). At birth, at least one person whose sole responsibility is neonatal resuscitation should be present to care for the baby (AAP & American Heart Association [AHA], 2006). Either this person or someone else who is immediately available should be able to perform a complete resuscitation, including endotracheal intubation and medication administration (AAP & AHA, 2006). It is not sufficient to have someone on call (either at home or in a remote area of the hospital) for newborn resuscitation at birth (AAP & AHA, 2006). Approximately 10% of babies need assistance to begin breathing at birth; about 1% of babies need extensive resuscitation to survive (AAP & AHA, 2006). Being fully prepared can potentially avoid a preventable adverse outcome.
Professional Standards and Guidelines for Emergent Cesarean Birth
* Review the AAP & ACOG (2002) and AAP & AHA (2006) guidelines for emergent cesarean birth preparedness to ensure that systems are in place to allow surgery to proceed as quickly as possible and that all members of the surgical team are readily available.
* Conduct periodic drills for emergent cesarean birth to promote team efficiency (JCAHO, 2004).
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