This was a retrospective observational study of the emergency caesarean sections carried out at the Department of Obstetrics and Gynaecology, AEFUTHA over a period of four years. The inclusion criteria were those who had singleton babies at term (between 37 and 42 weeks). The exclusion criteria were preterm deliveries, congenital anomalies, confirmed intrauterine foetal death before decision to deliver and parturients on opioids. Ethical approval was obtained from the Institution’s Review and Ethics Committee with approval number 23/08/2016-29/08/2016.

The case files of the women who delivered through emergency caesarean sections and met the inclusion criteria at AEFUTHA from 1^st January, 2012 to 1^st January, 2016 were retrieved from the medical records department, gynaecological emergency, labour ward, operating theatre.

The data extracted focused on socio-demographic and obstetric characteristics including age, parity, booking status, duration between decision for caesarean section and intervention, indications for the caesarean section, reasons for delay in DDI, association between booking status and DDI and association of 75, 90 and 240 minutes DDI and foetal outcome, APGAR score at 1^st and 5^th minutes and admission to NICU.

Data collection was done by trained research assistants who were registrars in the department. The data was collected using a pre-designed proforma. The collected data is immediately entered into the computer after verification by the researcher. Data analysis was done using Statistical Package for Social Sciences, IBM SPSS statistics version 20.0 (IBM Corp., Armonk, NY, USA). The results were expressed as frequency tables, percentages, mean and standard deviation. Multivariate analysis was performed to determine association between DDI at 75, 90 and 240 minutes. A p-value of 0.05 was considered statistically significant.

Over the study period, there were 8643 deliveries of which 1968 (22.7%) deliveries were through caesarean sections. Of the 1968 cases of caesarean sections, 1161 (58.9%) were emergency caesarean sections. Only 638 met the inclusion criteria of which 522 (81.8%) had complete record and were analysed. The hospital records of the remaining 116 could not be traced or have incomplete records and were excluded from the analysis. As shown in [Table/Fig-1], parturients between the age 21-30 years had the highest number (65.9%) of caesarean sections, while the least rate was among women above 41 years of age 3 (0.6%). Majority of the women 466 (89.3%) were para 1-4. Majority 497 (95.1%) of the women who had emergency caesarean section were married. About 235 (45%) parturient were booked, while 287 (55%) were unbooked. Majority 235 (45%) had secondary education as the highest level of education.

[Table/Fig-2] shows the indications for emergency caesarean sections. The most common indications for emergency caesarean section in this study were cephalopelvic disproportion 129 (24.7%), foetal distress 65 (12.5%) and antepartum haemorrhage 59 (11.3%). The least indication was cord prolapse 6 (1.1%). The mean decision deliver interval in this study was 189±124 minutes [Table/Fig-3]. Majority of the surgeries were performed within 121-180 minutes (mean 148.9±18.3 minutes), only 6 (1.1%) of the cases were performed within 30 minutes and 25 (4.7%) cases were performed within 60 minutes. About a fifth of cases 118 (22.6%) were performed beyond 240 minutes [Table/Fig-3].

[Table/Fig-4] depicts the reasons for delays indicating that delay in obtaining and cross-matching of blood for surgery accounted for 136 (26.1%). Others were delay in giving consent for surgery 67 (12.8%), stabilisation of patients 36 (6.9%), busy theatre suits 29 (5.6%), delay in carrying out laboratory investigation 82 (15.7%) and others 74 (14.2%).

[Table/Fig-5] indicates that of the 235 women who were booked, 27 delivered within 75 minutes and of the 287 unbooked participants only 18 delivered within 75 minutes (OR=1.65, CI=1.02-2.66, p-value=0.04).

The association between decision delivery intervals at cut-off points of 75, 90 and 240 minutes and foetal outcomes is shown in [Table/Fig-6]. The foetal outcome measures examined first and fifth minutes APGAR scores, admission into newborn special baby care unit as well as survival of the baby (live birth or stillbirth). Forty-five babies were delivered within 75 minutes, 79 babies within 90 minutes while 404 were delivered within 240 minutes. Among these, the odds of having APGAR score of 7-10 at the first minute were consistently lower with increase in time (AOR=2.48, CI=0.86-7.16) vs (AOR=1.09, CI=0.48-2.44) vs (AOR=0.78, CI=0.39-1.54). This was not statistically significant. Similar trend was also noted at the 5th minute APGAR score (AOR=2.24, CI=0.87-5.78) vs (AOR=2.1, CI=0.95-4.69) vs (AOR=1.048, CI=0.49-2.20). This was not statistically significant [Table/Fig-6].

A total of 198 babies were admitted in the NICU. Of these, 18 were delivered within 75 minutes, 31 within 90 minutes and 155 within 240 minutes. The odds of having a baby that will not be admitted into NICU decreased with increase in the cut-off time (AOR=2.08, CI=0.77-5.56) vs (AOR=1.21, CI=0.59-2.48) vs (AOR=0.78, CI=0.42-1.43). This was not found to be statistically significant [Table/Fig-7].

There were 18 perinatal deaths, four of which were delivered within 90 minutes, 15 were delivered within 240 minutes while only 3 were delivered beyond 240 minutes. The odds of having a live baby at 75, 90 and 240 minutes were (AOR=0.82, CI=0.17-3.79), (AOR=0.82, CI=0.21-3.24) and (AOR=1.76, CI=0.42-7.38), respectively. These were not found to be statistically significant [Table/Fig-7]. The indications for the caesarean section among babies that died were as shown in [Table/Fig-8]. Majority were due to prolonged obstructed labour and occurred between 90 minutes and 240 minutes of DDI. Early delivery within 75 minutes may have contributed in saving the lives of the death babies.

Most emergency caesarean sections that were performed in the current study were conducted after a decision delivery interval of more than 75 minutes. DDI >75 minutes was not significantly associated with higher APGAR scores (7-10) at both 1^st and 5^th minutes, with no significant risk of perinatal deaths and NICU admissions- indicating less adverse perinatal outcome. This could have been due to the close feto-maternal intra partum surveillance and optimum resuscitation for foetal heart rate abnormalities that were instituted during labour and decision delivery interval, when preparation for emergency delivery via caesarean section was being made.

There were only 1.1% emergency caesarean sections performed within 30 minutes and 4.7% performed within one hour. This result is similar to 0.86% performed within 30 minutes in Ogbomosho and 0.7% in Uganda [11,17] but lower than 5.7% and 12.3% performed within 30 minutes in Benin and Tanzania, respectively [8,18]. A study in Enugu, Nigeria showed that there was no emergency caesarean section performed with DDI of 30 minutes [7]. These findings compared to those of the present study suggest that some progress is being made in shortening DDI for emergency operative delivery in Nigeria. However, safe DDI is determined by each facility according to available resources. Resource constraint has made the recommended 30 minutes DDI difficult to implement in low resource setting.

The mean decision delivery interval of 189 minutes from this study is higher than the recommended 30 minutes [18]. The mean DDI is similar to the results obtained from other centres [5,15,19] where mean DDI of 200, 252 and 204 minutes, respectively were reported. It was higher than mean DDI of 39.5 minutes, 52.4 minutes and 42.5 minutes reported by other researcher from other studies [20-22]. The difference in the results obtained from centres in Nigeria and high income countries is an indication of the difference in advanced emergency service delivery and quality of health care services in western countries, hence emphasising the need for health system strengthening in Nigeria.

The practicability and implication on poor neonatal outcome was questioned because there was no strong evidence to support a 30 minute DDI in all cases. There was no correlation between DDI exceeding 75 minutes and adverse perinatal neonates.

The major causes of delays in this study were delay in procuring blood (26.1%), sorting out laboratory investigations (15.7%) and getting informed consent (12.8%). These are attributes of a weak health system and poor health seeking behaviour of the participants.

About 55% of the participants were unbooked and clinicians are often unsure of their baseline blood parameters. Owonikoko KM et al., recommended that it is safer in resource poor settings to ensure that blood is made available before commencing surgery especially for patients who are at risk of bleeding, as cross-matching of blood and securing rare blood group types may take time and increase DDI and the risk the mother and baby are likely to face from this delays [11]. Occasionally, laboratory staff may not understand the dire emergency in some clinical scenario and the need to urgently group and cross-match blood and blood products, sometimes resulting in delays which prolongs DDI. In Benin the main cause of delay was anaesthetic delay and busy theatre suits [8]. Owonikoko KM et al., observed that the major cause of delay in their study was due to lack of funds and non provision of surgical materials but also noted non-availability of blood and blood products contributed to the delays reported [11]. They also reported that patients’ relatives usually pay surgical fees and also buy materials before the operation could be performed, making out of pocket financing a contributor to the delay. Studies have shown that, out of pocket financing of health care is associated with poor maternal and perinatal outcomes [23]. Onah HE et al., in Enugu, Nigeria, identified delay in assembly of personnel for surgery and non-readiness of the operating theatre which may be attributed to dearth of appropriate staff in their centre at that time [7].

Antenatal attendance was also a factor, as unbooked women were almost twice more likely to be delivered beyond 75 minutes. Unbooked status is an identified risk factor for increased maternal and perinatal morbidity and mortality in obstetrics. Furthermore, they often present to the hospital unprepared, with no money to purchase consumables and pay for investigations in a health system without universal health insurance. They are also unwilling to donate or procure blood, this constitute a major contributors to delay in decision to surgical delivery.

The present study shows that babies delivered beyond 75 minutes of decision to deliver have lower odd of having good APGAR scores of 7-10 at the first and fifth minutes. This was not found to be statistically significant. Similarly, the chances of admission into NICU increase beyond 75 minutes of DDI. This was also not statistically significant. Although not statistically significant, the overall perinatal outcome of the babies does not appear to worsen over time suggesting that other factors may contribute to the survival of the babies. Hirani BA et al., showed that babies born after 75 minutes have higher odd of having APGAR score of less than 7 in the first and fifth minutes though this was not found to be statistically significant [20]. The implication is that the duration of DDI <75 minutes did not confer better or improved perinatal outcome. This is similar to the finding in Ogbomosho, Southwest, Nigeria, were 5 minutes APGAR scores, admission to NICU and perinatal mortality were not related to DDI [10]. A similar study in Uganda reported that DDI did not affect maternal and perinatal outcomes [15]. However, caution must be applied in patient care, despite the lack of correlation between DDI and poor perinatal outcome, as unnecessarily prolonged DDI may be unjustified and may results in morbidity and mortality.

The medical records were intact and complete, however, due to the retrospective nature of the study; it was not possible to evaluate on individual basis some of the causes of delay specific to staff challenges and anaesthetic difficulties. Prospective studies should be done to identify specific causes of the delay and study in details the DDI in relation to different clinical scenario.

There was no association between DDI >75 minutes and poor perinatal outcome. Efforts should be made to strengthen the health system and improve the quality of care in order to keep DDI within this time limit for improved perinatal and maternal health and indices.