Accepted Manuscript Decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for nonreassuring fetal heart rate (NRFHR) Shashikant L. Sholapurkar, MD, DNB, MRCOG PII:
S0002-9378(14)00370-6
DOI:
10.1016/j.ajog.2014.04.016
Reference:
YMOB 9785
To appear in:
American Journal of Obstetrics and Gynecology
Received Date: 17 March 2014 Accepted Date: 11 April 2014
Please cite this article as: Sholapurkar SL, Decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for non-reassuring fetal heart rate (NRFHR), American Journal of Obstetrics and Gynecology (2014), doi: 10.1016/j.ajog.2014.04.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
ACCEPTED MANUSCRIPT
Title Page Letter to the Editor
RI PT
Decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for nonreassuring fetal heart rate (NRFHR)
Mr Shashikant L SHOLAPURKAR
SC
Author:
M AN U
MD, DNB, MRCOG Department of Obstetrics and Gynaecology,
Royal United Hospital Bath NHS Trust, Bath, United Kingdom Author has no conflict of interest to report
Financial support:
None
Mr Shashikant L SHOLAPURKAR
EP
Corresponding Author:
TE D
Disclosure:
Department of Obstetrics and Gynaecology, Princess Anne Wing, Royal United Hospital
e-mail: Tel:
AC C
Bath NHS Trust, Combe Park, Bath, BA1 3LE, United Kingdom. [email protected]
Business 44 (0)1225 428331, Fax: 44 (0)1225 825464, Home: 44(0)1225 423829
Word Count:
363
2
ACCEPTED MANUSCRIPT Letter to the Editor, Decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for nonreassuring fetal heart rate (NRFHR) – A Bayesian approach to the 30-minute standard.
RI PT
Dear Editor, The well conducted prospective study by Weiner et al1 could be considered a very good quality evidence for a 30-minute DDI standard especially as RCTs are not possible on
SC
this subject. However, in addition to the limitations outlined (confounding factors, Hawthorne effect, variable characterization of NRFHR etc.)1; the results of this study may not alter the
M AN U
current practice trend in the USA and UK. This is because the ‘prior belief’ about the validity and practicality of the arbitrary 30-minute standard has changed considerably and a Bayesian approach is likely to be the norm. In the UK it took the anaesthetists (who observed Obstetrician’s distress) to test and propose a four-category classification of timing of all
TE D
caesareans 2 now accepted nationally. 3 The ECS for NRFHR would constitute the categories1 and 2 cesareans (not to be confused with 3-tier FHR classification). Only those cases of NRFHR associated with a rapidly deteriorating pattern or an acute accident (abruption, cord
EP
prolapse, uterine rupture etc.) fall in Category-1 where a 30-minute standard applies with a recommendation to deliver the baby even more expeditiously as possible. There is some
AC C
confusion about the DDI (30-90 minutes?) 3 for Category-2 cesareans for non-dire NRFHR and the author is currently conducting a study to test pertinent practice recommendations. Unqualified adherence to the 30-minute standard increases incidence of general anaesthesia, causes more distress to the patients / relatives, requires extra resources (already overstretched) round the clock and has medico-legal implications. It also does not have a scientific basis or a valid underlying hypothesis. Most NRFHRs in current practice indicate a possibility of potential serious fetal acidemia developing if labour is allowed to continue.
3
ACCEPTED MANUSCRIPT Vast majority cases of NRFHR in the USA would be in the Category II (of 3-tier classification of FHR patterns) combined with additional criteria. 4 This pattern may need to be present for 30-60 minutes and could even be further observed if labour was progressing normally.4 Hence, there does not seem to be a valid hypothesis for an indiscriminate
cannot be made
3
RI PT
application of the 30-minute DDI. Rigid recommendations for DDI for NRFHR probably and some degree of individualization within the context of a 2-tier
Shashikant L. Sholapurkar, MD, DNB, MRCOG
M AN U
References
SC
framework for ECS seems desirable.
1. Weiner E, Bar J Fainstein N, et al. The effect of a program to shorten the decision-todelivery interval for emergent cesarean section on maternal and neonatal outcome.
TE D
Am J Obstet Gynecol 2014;210:224.e1-6.
2. Lucas DN, Yentis SM, Kinsella SM, et al. Urgency of caesarean section: a new
EP
classification. J R Soc Med 2000;93:346-50.
AC C
3. National Collaborating Centre for Women's and Children's Health (UK). Caesarean Section. London: RCOG Press; 2011 Nov.
4. Clark SL, Nageotte MP, Garite TJ, et al. Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J Obstet Gynecol 2013;209:89-97.
S0002-9378(14)00370-6
DOI:
10.1016/j.ajog.2014.04.016
Reference:
YMOB 9785
To appear in:
American Journal of Obstetrics and Gynecology
Received Date: 17 March 2014 Accepted Date: 11 April 2014
Please cite this article as: Sholapurkar SL, Decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for non-reassuring fetal heart rate (NRFHR), American Journal of Obstetrics and Gynecology (2014), doi: 10.1016/j.ajog.2014.04.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
ACCEPTED MANUSCRIPT
Title Page Letter to the Editor
RI PT
Decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for nonreassuring fetal heart rate (NRFHR)
Mr Shashikant L SHOLAPURKAR
SC
Author:
M AN U
MD, DNB, MRCOG Department of Obstetrics and Gynaecology,
Royal United Hospital Bath NHS Trust, Bath, United Kingdom Author has no conflict of interest to report
Financial support:
None
Mr Shashikant L SHOLAPURKAR
EP
Corresponding Author:
TE D
Disclosure:
Department of Obstetrics and Gynaecology, Princess Anne Wing, Royal United Hospital
e-mail: Tel:
AC C
Bath NHS Trust, Combe Park, Bath, BA1 3LE, United Kingdom. [email protected]
Business 44 (0)1225 428331, Fax: 44 (0)1225 825464, Home: 44(0)1225 423829
Word Count:
363
2
ACCEPTED MANUSCRIPT Letter to the Editor, Decision-to-delivery interval (DDI) for emergency cesarean section (ECS) for nonreassuring fetal heart rate (NRFHR) – A Bayesian approach to the 30-minute standard.
RI PT
Dear Editor, The well conducted prospective study by Weiner et al1 could be considered a very good quality evidence for a 30-minute DDI standard especially as RCTs are not possible on
SC
this subject. However, in addition to the limitations outlined (confounding factors, Hawthorne effect, variable characterization of NRFHR etc.)1; the results of this study may not alter the
M AN U
current practice trend in the USA and UK. This is because the ‘prior belief’ about the validity and practicality of the arbitrary 30-minute standard has changed considerably and a Bayesian approach is likely to be the norm. In the UK it took the anaesthetists (who observed Obstetrician’s distress) to test and propose a four-category classification of timing of all
TE D
caesareans 2 now accepted nationally. 3 The ECS for NRFHR would constitute the categories1 and 2 cesareans (not to be confused with 3-tier FHR classification). Only those cases of NRFHR associated with a rapidly deteriorating pattern or an acute accident (abruption, cord
EP
prolapse, uterine rupture etc.) fall in Category-1 where a 30-minute standard applies with a recommendation to deliver the baby even more expeditiously as possible. There is some
AC C
confusion about the DDI (30-90 minutes?) 3 for Category-2 cesareans for non-dire NRFHR and the author is currently conducting a study to test pertinent practice recommendations. Unqualified adherence to the 30-minute standard increases incidence of general anaesthesia, causes more distress to the patients / relatives, requires extra resources (already overstretched) round the clock and has medico-legal implications. It also does not have a scientific basis or a valid underlying hypothesis. Most NRFHRs in current practice indicate a possibility of potential serious fetal acidemia developing if labour is allowed to continue.
3
ACCEPTED MANUSCRIPT Vast majority cases of NRFHR in the USA would be in the Category II (of 3-tier classification of FHR patterns) combined with additional criteria. 4 This pattern may need to be present for 30-60 minutes and could even be further observed if labour was progressing normally.4 Hence, there does not seem to be a valid hypothesis for an indiscriminate
cannot be made
3
RI PT
application of the 30-minute DDI. Rigid recommendations for DDI for NRFHR probably and some degree of individualization within the context of a 2-tier
Shashikant L. Sholapurkar, MD, DNB, MRCOG
M AN U
References
SC
framework for ECS seems desirable.
1. Weiner E, Bar J Fainstein N, et al. The effect of a program to shorten the decision-todelivery interval for emergent cesarean section on maternal and neonatal outcome.
TE D
Am J Obstet Gynecol 2014;210:224.e1-6.
2. Lucas DN, Yentis SM, Kinsella SM, et al. Urgency of caesarean section: a new
EP
classification. J R Soc Med 2000;93:346-50.
AC C
3. National Collaborating Centre for Women's and Children's Health (UK). Caesarean Section. London: RCOG Press; 2011 Nov.
4. Clark SL, Nageotte MP, Garite TJ, et al. Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J Obstet Gynecol 2013;209:89-97.
