Decision to delivery interval in cesarean delivery for suspected fetal distress: the risk factors and outcomes


  • Zahar Azuar Zakaria Department of Obstetrics and Gynaecology, Hospital Kemaman, Terengganu, Malaysia
  • Maria Muhammad Department of Obstetrics and Gynaecology, Hospital Kemaman, Terengganu, Malaysia



Caesarean delivery, Delivery interval, Fetal distress


Background: This study was to evaluate the differences in the neonatal outcomes after caesarean sections (CS) for suspected fetal distress in groups with decision to delivery interval (DDI) of 30 minutes or less and longer than 30 minutes. Factors associated with these intervals were also investigated.

Methods: Data were retrospectively collected from all emergency caesarean deliveries for fetal distress in 2021. Maternal demographic data, the procedure characteristics and the neonatal outcomes were analyzed according to the DDI groups; 30 minutes or less and more than 30 minutes. Time interval for different stages of DDI and related factors were also analyzed.

Results: A total of 115 cases were included for analysis with the mean DDI of 40.1 minutes. Only 24/115 (20.9%) of the cases had the DDI of 30 minutes or less. Maternal and surgical characteristics were similar between the 2 study groups, and there were no differences in the proportion of neonatal acidosis, low Apgar score, intubation, NICU admission and the mean umbilical cord pH or base excess. Regression analysis demonstrated that level of surgeon’s experience, operations during the normal working hours or CS for fetal bradycardia were significantly associated shorter DDI. Experienced surgeon and unscarred uterus were associated with shorter incision to neonatal delivery interval.

Conclusions: The longer DDI in caesarean deliveries for suspected fetal distress is not associated with significant adverse neonatal outcomes. Despite so, identifying the factors influencing the DDI is still an important aspect in the constant work to improve the obstetric service.


Leung TY, Lao TT. Timing of caesarean section according to urgency. Best Pract Res Clin Obstet Gynaecol. 2013;27:251-67.

Chauhan SP, Roach H, Naef RW, Magann EF, Morrison JC, Martin JN. Cesarean section for suspected fetal distress. Does the decision-incision time make a difference? J Reprod Med. 1997;42:347-52.

Bloom SL, Leveno KJ, Spong CY, Gilbert S, Hauth JC, Landon MB, et al. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Decision-to-incision times and maternal and infant outcomes. Obstet Gynecol. 2006; 108(1):6-11.

Roy KK, Baruah J, Kumar S, Deorari AK, Sharma JB, Karmakar D. Cesarean section for suspected fetal distress, continuous fetal heart monitoring and decision to delivery time. Indian J Pediatr. 2008;75(12):1249-52.

Tolcher MC, Johnson RL, El-Nashar SA, West CP. Decision-to-incision time and neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol. 2014;123(3):536-48.

Lim Y, Shah MK, Tan HM. Evaluation of surgical and anaesthesia response times for crash caesarean sections--an audit of a Singapore hospital. Ann Acad Med Singap. 2005;34(10):606-10.

Leung TY, Chung PW, Rogers MS, Sahota DS, Lao TT, Hung Chung TK. Urgent cesarean delivery for fetal bradycardia. Obstet Gynecol. 2009;114(5):1023-8.

May RL, Clayton MA, Richardson AL, Kinsella SM, Khalil A, Lucas DN. Defining the decision-to-delivery interval at caesarean section: narrative literature review and proposal for standardization. Anaesthesia. 2022; 77(1):96-104.

Dore S, Ehman W. Fetal health surveillance: intrapartum consensus guideline. J Obstet Gynaecol Can. 2020;42(3):316-48.

MacLennan A. A template for defining a causal relation between acute intrapartum events and cerebral palsy: international consensus statement. BMJ. 1999; 319(7216):1054-9.

Rogers MS. Obesity: preventing and managing the global epidemic: report of a WHO consultation. Tech Rep Ser. 2000;894:1-253.

American Academy of Pediatrics. Guidelines for perinatal care. 5th ed. Washington DC: ACOG Publishers; 2017:267.

National Collaborating Centre for Women's and Children's Health (UK). Available at: https://www. Accessed on 20 November 2022.

Hirani BA, Mchome BL, Mazuguni NS, Mahande MJ. The decision delivery interval in emergency caesarean section and its associated maternal and fetal outcomes at a referral hospital in northern Tanzania: a cross-sectional study. BMC Preg Childbirth. 2017;17(1):411.

Khemworapong K, Sompagdee N, Boriboonhirunsarn D. Decision-to-delivery interval in emergency cesarean delivery in tertiary care hospital in Thailand. Obstet Gynecol Sci. 2018;61(1):48-55.

Kitaw TM, Limenh SK, Chekole FA, Getie SA, Belete N, Gemeda BN, et al. Decision to delivery interval and associated factors for emergency cesarean section: a cross-sectional study. BMC Preg Childbirth. 2021;21: 224.

Kwek K, Yeap ML, Tan KH, Tee JC, Yeo GS. Crash caesarean section-decision-to-delivery interval. Acta Obstet Gynecol Scand. 2005;84(9):914-5.

Brandt JA, Morgenstern B, Thangarajah F, GrÜttner B, Ludwig S, Eichler C, et al. Evaluating the Decision-to-Delivery Interval in Emergency Cesarean Sections and its Impact on Neonatal Outcome. In Vivo. 2020;34(6): 3341-7.

Kolas T, Hofoss D, Oian PA. Predictions for the decision-to-delivery interval for emergency cesarean sections in Norway. Acta Obstet Gynecol. 2006;85: 561-6.

Chauleur C, Collet F, Furtos C, Nourrissat A, Seffert P, Chauvin F. Identification of factors influencing the decision-to-delivery interval in emergency caesarean sections. Gynecol Obstet Invest. 2009;68(4):248-54.

Wong TCT, Lau CQH, Tan EL, Kanagalingam D. Decision-to-delivery intervals and total duration of surgery for Caesarean sections in a tertiary general hospital. Singapore Med J. 2017;58(6):332-7.

Morales KJ, Gordon MC, Bates GW. Postcesarean delivery adhesions associated with delayed delivery of infant. Am J Obstet Gynecol. 2007;196(5):461.e1-6.

Spencer MK, and MacLennan AH: How long does it take to deliver a baby by emergency caesarean section? Aust N Z J Obstet Gynaecol. 2001;41(1):7-11.

Wong L, Tse WT, Lai CY, Hui ASY, Chaemsaithong P, Sahota DS, et al. Bradycardia-to-delivery interval and fetal outcomes in umbilical cord prolapse. Acta Obstet Gynecol Scand. 2021;100(1):170-7.

MacKenzie IZ, Cooke I. What is a reasonable time from decision-to-delivery by caesarean section? Evidence from 415 deliveries. BJOG. 2002;109(5): 498-504.

Pulman KJ, Tohidi M, Pudwell J, Davies GAL. Emergency caesarean section in obese parturients: Is a 30-Minute Decision-to-Incision Interval Feasible?. J Obstet Gynaecol Can. 2015;37(11):988-94.

Conner SN, Tuuli MG, Longman RE, Odibo AO, Macones GA, Cahill AG. Impact of obesity on incision-to-delivery interval and neonatal outcomes at cesarean delivery. Am J Obstet Gynecol. 2013;209(4): 386.e1-6.

Chow KM, Mak SL. Maternal and fetal outcomes in extremely urgent caesarean delivery in relation to the decision-to delivery interval. Hong Kong J Gynaecol Obstet Midwifery. 2015;15(1):16-22.

Mitouard ML, Gaucher L, Huissoud C, Gaucherand P, Rudigoz RC, Dupont C, et al. Decision-delivery intervals: Impact of a colour code protocol for emergency caesareans. Eur J Obstet Gynecol Reprod Biol. 2020;246:29-34.

Boriboonhirunsarn D, Sunsaneevithayakul P. A specific protocol to shorten the decision-to-delivery interval for emergency caesarean section. BJOG. 2010;83(8):235-9.






Original Research Articles