Running head: CESAREAN DELIVERY
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Decision to Incision
Kristie Bruesch
NURS 440
Ferris State University
CESAEREAN DELIVERY
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Abstract
This article will look at studies comparing cesarean delivery times and statistics at North Ottawa
Community Health System (NOCHS). The study will look at past trends in cesarean delivery
times and find a solution to create a safer time frame from the decision to incision time.
Determine essential personnel needed to perform an emergent cesarean delivery. Establish
required equipment for an emergent cesarean delivery and the process for each individual. With
the gathering of information through various employees affected by a cesarean delivery will help
prepare a woman and her family for cesarean delivery and provide prompt, timely,
knowledgeable support for the emergency cesarean delivery.
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History on Cesarean Delivery
When a pregnant woman presents to a delivery unit in labor, the woman’s fetus is
assessed with a fetal heart monitor. During the labor process, the fetus can become stressed
causing concern to perform an emergent cesarean delivery. Reasons for an emergent cesarean
delivery can be; placental abruption, uterine rupture, umbilical cord prolapsed, fetal distress, and
preeclampsia. Other reasons for urgent or scheduled cesarean deliveries include placental previa,
breech presentation, birth defects, active genital herpes, cephalopelvic disproportion and failure
to progress in labor (Association, 2006).
The Center for Disease Control (CDC) shows 30.2% of deliveries in the United States
were performed by Cesarean Delivery (CDC, 2007). With this high of a percentage creates the
need to assure prompt timing of an emergent cesarean delivery. The current standard is to
perform a cesarean delivery in a timing of <30 minutes from the time a decision was made for a
cesarean delivery to the time the initial incision was made for the cesarean delivery, otherwise
known as decision to incision (Nageotte & Vanderwal, 2011).
It has been brought to the attention through statistics, of Clinical Coordinator Danielle
Felty (2011), NOCHS decision to incision rate is over the <30 minute time frame. With this fact,
concern is caused for an increased risk of fetal well being at delivery time. In past trends,
statistics are scored using the house supervisor obtaining information on the current emergent
cesarean deliveries and recording the decision to incision time.
Past Trends
The past method used to determine a cesarean delivery is needed follows the provider
assessing the patient in person, making the decision, and informing the nurse of the decision. The
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nurse then pages the house supervisor, with critical minutes passing until the page is returned,
the nurse prepares the patient. In preparation of the patient, the nurse must obtain consents, place
a Foley catheter into the bladder, give ordered medication, initiate an IV, pubic shave
preparation, offer support to the patient and family and wait until surgery crew is ready for the
patient. Once the house supervisor is notified of the need for a surgery crew, the house
supervisor must call each individual on the surgery crew which consists of; the anesthesiologist,
a scrub technician, a pediatrician, a provider assistant, and the nurse circulator.
Once the crew is on the delivery unit, the anesthesiologist informs the patient of
highlighted risks for general anesthesia or the possible spinal anesthesia. The patient is brought
to the operating room (OR) and prepared for surgery. In the operating room, a brief history is
given to the OR team, a time out is performed, accurate count of needed equipment performed,
abdominal preparation done, patient is either intubated or a spinal anesthesia is injected. At this
point the incision is performed, giving the time for decision to incision.
Addressing the Problem
Noting NOCHS incision to decision time frame is over the <30 minute standard, raises
the need to address the situation and provide a solution. A program called “LEAN” was
introduced to inspect the issue. The program consisted of the delivery unit manager, two
registered nurses working on the delivery unit, a house supervisor, an anesthesiologist, a
circulator, a scrub technician, the head pediatrician, and the manager of the OR.
During the LEAN process, each individual wrote down problems to address. After
reviewing the problems, the most concerns needing to be addressed were as follows;
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1. Having a limited number of staff members with variable levels of training on off
shifts
2. Not all providers in the delivery unit can perform a cesarean delivery
3. Coordinating the surgical team in an organized fashion
4. Having the patient prepped and ready for surgery prior to the OR crew being ready
5. House Supervisor having to many obligations
All team members of the LEAN agreed with each issue. The next step is creating an innovative
process to decreasing each problem.
Goals to a Successful Method
Goals were created to maintain an on track method to improve the decision to incision
method.
Goal #1: To ensure decision to incision time remains under <30 minutes
Goal #2: To ensure patient safety remains the highest value
Goal #3: To ensure every team member is properly trained
Creating Better Methods
The first method is paging the House Supervisor (HS) once the decision is made. If the
nurse or the provider making the decision has an idea of an impending cesarean delivery the HS
should be notified at this time. If the decision is sporadic and emergent, the nurse or provider is
to phone the operator at extension zero. State to the operator, “I need a STAT c-section paged”.
In collaborating with the OR crew, all on-call staff will carry a pager. When the operator hears
this STAT call, there will be an automated calling system activated which will paged all needed
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personnel for the cesarean delivery, even the HS. Also, the operator will page a “Code Pink”
overhead to alert other elected in house staff members to present to the OR to help in
preparation. At the time the page is collected by the HS, he/she will present to the delivery unit
to assist with any desk duties and await return phone calls from the individuals paged. Once the
nurse or provider activates the emergent paging system, the nurse will bring the patient back in
her own bed to the OR and begin doing all needed preparation with the assist of another RN on
staff in the delivery unit and those presenting from the “Code Pink”. Patient support will be
performed in the OR during preparation. Social work is paged to provide family support.
To help in decreasing time, the anesthesiologist has created a pre-questionnaire for all
obstetric patients presenting in labor. Once completed, the questionnaire will be placed in the
chart under the OR section to be readily viewed by the anesthesiologist. A checklist was created
for the RN caring for the patient to help the circulator with handing off the patient.
In the OR, an emergent cesarean delivery pack was created. In this event, the nurse can
open the pack and all needed emergent equipment is exposed. Including in the pack is Lidocaine
in order to perform a local cesarean delivery in case the OR crew has yet to present to OR and
fetal distress continues. Once the patient is back in OR, the HS, provider, emergency room
provider, and two nurses on staff will begin initiating the cesarean delivery until the OR crew
arrives. The emergency room provider can initiate short term intubation until anesthesia presents
if needed.
Resulting the Method
This process has been documented in a NOCHS policy (Phipott, Vankampen,
Schexnaydre, & Capilli, 2011) and is carried out in yearly mock drills. Over the past year, per
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Clinical Coordinator Danielle Felty (2011), studies have shown a dramatic decrease in timing
decision to incision times with the collection of reporting a decision to incision timeframe when
a STAT cesarean delivery is performed. The allotted time of <30 minutes has been reached in
every scenario including urgent cesarean deliveries. Patient safety has remained to be the highest
priority and every team member involved in a cesarean delivery scenario has been trained.
Conclusion
To remain an effective organization, facilities must look at prior procedures. Reviews
must be initiated with all coordinating members to promote patient safety, especially in rural area
hospitals. Given the LEAN procedure, patient safety is shown at a high priority to reduce
prolonged fetal distress. In simple restructuring of a procedure, fetal distress is now limited to
<30 minutes creating better patient outcomes.
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References
Association, A. P. (2006). Reasons for a Cesarean Birth. Retrieved 2011, from American
pregnancy association:
http://www.americanpregnancy.org/labornbirth/reasonsforacesarean.html
CDC. (2007). Percentage of All Live Births by Cesarean Delivery . Retrieved 2011, from Center
for disease control: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5615a8.htm
Felty, D. (2011). Decision to Incision. (K. Bruesch, Interviewer)
Nageotte, M., & Vanderwal, B. (2011). Achievement of the <30 minute standard in obstectrics.
Retrieved 2011, from American journal of obstectrics and gynecology: http://0www.sciencedirect.com.libcat.ferris.edu/science/article/pii/S0002937811011732
Phipott, D., Vankampen, C., Schexnaydre, E., & Capilli, C. (2011). C-section- Scheduled or
Emergent- pre op care. Policy 10-H-87 . Michigan: North ottawa community hospital.