How quickly can a cesarean section (C-section) be performed after the decision to operate?

How Quickly Can a C-Section Be Performed

A cesarean section can typically be performed within 30 minutes from the decision to operate in standard emergency situations, while in extreme emergencies such as maternal cardiac arrest, delivery should occur within 5 minutes of arrest onset to optimize maternal and fetal survival. 1

Standard Emergency C-Section Timeline

The Enhanced Recovery After Surgery (ERAS) Society guidelines establish a "focused" pathway for cesarean delivery that begins 30-60 minutes before skin incision for both scheduled and unscheduled cesarean deliveries 1. This timeline includes:

• Decision-to-delivery interval (DDI): The recommended standard is 30 minutes or less for emergency cesarean sections 2
• Preparation phase (30-60 minutes before incision):
  • Administration of prophylactic antibiotics within 60 minutes before skin incision 1
  • Skin preparation with chlorhexidine-alcohol 1
  • Anesthesia preparation (regional anesthesia preferred) 1

Factors Affecting C-Section Speed

Several factors can impact how quickly a cesarean section can be performed:

1. Type of emergency:

   • Category 1 emergencies (immediate threat to life): Mean DDI of 36.3 ± 17.2 minutes 2
   • Category 2 emergencies (maternal or fetal compromise): Mean DDI of 38.1 ± 17.7 minutes 2

2. Common causes of delay:

   • Delay in transferring patient to operating room (22.1%) 2
   • Anesthesia-related factors (18.1%) 2
   • Lack of resources or manpower (16.1%) 2

3. Type of anesthesia:

   • General anesthesia allows for faster delivery 3, 4
   • Spinal anesthesia placed in the operating room significantly delays extraction time 3
   • Pre-existing epidural can be faster with 91.9% of cases meeting the 30-minute target 3

Extreme Emergency: Perimortem C-Section

In cases of maternal cardiac arrest with a gravid uterus:

• Emergency cesarean section team should be activated immediately at the onset of maternal cardiac arrest 1
• Delivery should occur within 5 minutes after the mother's heart stops beating for optimal infant survival (>24-25 weeks gestation) 1
• Begin hysterotomy approximately 4 minutes after cardiac arrest if there is no return of spontaneous circulation 1
• Do not transport the patient to an operating theater in this scenario; perform the procedure where the arrest occurs 1

Outcomes Related to Timing

• Maternal outcomes: Significant association between longer DDI and adverse maternal outcomes. In one study, maternal non-survivors had a DDI of 91.0 ± 97.0 minutes compared to 36.8 ± 15.7 minutes for survivors 2
• Fetal outcomes:
  • Best survival rate occurs when delivery is within 5 minutes of maternal cardiac arrest 1
  • At gestational ages >30 weeks, infant survival has been documented even with delivery after 5 minutes from onset of maternal cardiac arrest 1
  • Neonatal survival has been documented with delivery within 30 minutes after onset of maternal cardiac arrest 1

Realistic Expectations

Despite guidelines recommending a 30-minute DDI:

• Only 42.4% of emergency C-sections meet the 30-minute target 2
• Even in optimal settings with 24-hour obstetrical, anesthesia, and neonatal services, the 90th percentile for DDI was 22 minutes, occasionally exceeding recommended times 5
• A universal standard of 100% compliance with the 30-minute target is considered unrealistic 6

Key Points for Optimal Response

1. Use structured time sheets and protocols for extreme emergencies 3, 6
2. Ensure coordinated teamwork between obstetrics, anesthesia, and neonatology 5
3. Consider the type of anesthesia based on urgency - general anesthesia for the most time-critical situations 4
4. In maternal cardiac arrest, perform the C-section where the arrest occurs rather than transporting the patient 1

The speed of cesarean delivery is critical for both maternal and fetal outcomes, particularly in true emergencies, but realistic expectations should acknowledge that the recommended timelines cannot always be achieved despite best efforts.