O&G · Intrapartum care — operative birth
Caesarean urgency categorisation and timing at term
Also known as Caesarean urgency category · Category 1 caesarean · Decision-to-delivery interval · Decision-to-birth interval · DDI · Lucas classification · Timing of elective caesarean · 39 week rule
Exam-exhaustive FRANZCOG reference on how urgent a caesarean is and when a planned one should happen — the four-category Lucas classification, the RANZCOG C-Obs 14 position that no time is attached to any category, the NICE 30 and 75 minute audit standards and what the DDI evidence actually shows, and the gestation-by-gestation neonatal respiratory data behind the 39-week rule in C-Obs 23. RANZCOG-primary, globally tagged.
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Red flags
- Calling a category 1 and then behaving like a category 2 — the words must change the room, or they mean nothing
- Assigning a category once and never reassessing it as the trace, the cervix or the theatre queue changes
- Judging the interval by the condition of the baby at birth instead of by what you knew when you decided
- Rushing a general anaesthetic to protect a 30-minute number when the fetal indication did not require it
- Booking a planned caesarean before 39 weeks with no reason written in the notes
- A category 2 displaced three times by other emergencies — it is now urgent, and nobody has said so
It is 22:40 and the registrar shouts "category 1" from the doorway of room 4. Everything that happens in the next twenty minutes was decided by that phrase — who runs, who scrubs, whether the anaesthetist tops up the epidural or reaches for thiopentone. Say the wrong word and the room moves at the wrong speed. This topic is about getting that word right, and about the quieter version of the same problem: which day you write on the elective list.[1][6]
Overview and definition
Two separate questions live under one heading, and examiners test both. How fast? applies to the unplanned caesarean. What day? applies to the planned one. They are joined by a single principle: the timing of a caesarean is a clinical decision with a stated reason, never a default.[1][8]
- Decision-to-birth interval (DDI) — from moment responsible clinician decides to operate, to the birth of the baby. Some units and most American literature use decision-to-incision instead, which stops the clock earlier.[5][6]
- Planned (pre-labour) caesarean — booked in advance, before labour. Unplanned caesarean happens once labour or a complication has begun. The old elective / emergency pair is being retired because "emergency" flattens a category 1 and a category 3 into one word.[1]
- Early term is 37+0 to 38+6, full term 39+0 to 40+6. That boundary at 39+0 is where the neonatal respiratory data changes shape.[7][8]
References16ShowHide
- [1]Lucas DN, Yentis SM, Kinsella SM, et al. Urgency of caesarean section: a new classification. J R Soc Med, 2000.PMID 10928020
- [2]Thomas J, Paranjothy S, James D National cross sectional survey to determine whether the decision to delivery interval is critical in emergency caesarean section. BMJ, 2004.PMID 15023829
- [3]Tuffnell DJ, Wilkinson K, Beresford N Interval between decision and delivery by caesarean section-are current standards achievable? Observational case series. BMJ, 2001.PMID 11387177
- [4]MacKenzie IZ, Cooke I Prospective 12 month study of 30 minute decision to delivery intervals for "emergency" caesarean section. BMJ, 2001.PMID 11387178
- [5]Bloom SL, Leveno KJ, Spong CY, et al. Decision-to-incision times and maternal and infant outcomes. Obstet Gynecol, 2006.PMID 16816049
- [6]Tolcher MC, Johnson RL, El-Nashar SA, et al. Decision-to-incision time and neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol, 2014.PMID 24499762
- [7]Hansen AK, Wisborg K, Uldbjerg N, et al. Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ, 2008.PMID 18077440
- [8]Tita AT, Landon MB, Spong CY, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med, 2009.PMID 19129525
- [9]Tita ATN, Lai Y, Landon MB, et al. Timing of elective repeat cesarean delivery at term and maternal perioperative outcomes. Obstet Gynecol, 2011.PMID 21252740
- [10]Glavind J, Kindberg SF, Uldbjerg N, et al. Elective caesarean section at 38 weeks versus 39 weeks: neonatal and maternal outcomes in a randomised controlled trial. BJOG, 2013.PMID 23682628
- [11]Stutchfield P, Whitaker R, Russell I; Antenatal Steroids for Term Elective Caesarean Section (ASTECS) Research Team Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section: pragmatic randomised trial. BMJ, 2005.PMID 16115831
- [12]Sotiriadis A, Makrydimas G, Papatheodorou S, et al. Corticosteroids for preventing neonatal respiratory morbidity after elective caesarean section at term. Cochrane Database Syst Rev, 2018.PMID 30075059
- [13]Betran AP, Torloni MR, Zhang JJ, et al. WHO Statement on Caesarean Section Rates. BJOG, 2016.PMID 26681211
- [14]Boerma T, Ronsmans C, Melesse DY, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet, 2018.PMID 30322584
- [15]Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol, 2006.PMID 16738145
- [16]Keag OE, Norman JE, Stock SJ Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med, 2018.PMID 29360829