Decision Delivery Interval (DDI)

vs Bradycardia Delivery Interval (BDI)

“The Evidence”

Objectives

Fetal benefits?

Maternal Harm?

30

mins

Overview

Urgency of caesarean section

Decision delivery interval / Decision incision interval (DDI)

Bradycardia decision interval (BDI)

“3 min rule”

Urgency

Crash caesarean section - 0.6 – 0.7%

Increase duration of anoxia – increased incidence of HIE

Classification of caesarean section

Decision

delivery

interval ?

Hypothesis - Duration of fetal hypoxia = Degree

of HIE

Consensus

i) Decision delivery interval (DDI) – 30mins

ii) Decision incision interval (DII) – 30mins

30min rule?

Does 30mins – improve perinatal

outcomes?

Achievable? Negligence?

Studies on monkeys – 10mins –

irreversible cerebral injury

Case studies on uterine rupture –

irreversible HIE in 18mins

DDI

The Origin

1950’s – 1968 – studies in US – average duration –

15- 43mins

Nationwide survey in US – 538 hospitals (1988) –

almost all hospitals achieved delivery within 30mins

This was later adopted by UK, RCOG, Clinical

Negligence Schemes . Remains a consensus by

ACOG & American Association of Paediatrics

German Society of O&G – DDI – 20mins

“

”

All units should be capable to

deliver within 30 minutes

ACOG

American Academic of Pediatricians

DDI –

evidence

Conflicting

Some studies – better outcomes > 30mins – in

utero resuscitation

Some studies – no difference if fetus delivered >

75 minutes

Some causes are reversible – tachysystole, post

epidural

Average delivery time for category 1 & 2

UK National Sentinel audit for caesarean section

2 month audit

17780 births

DD1 15 Vs 16-75 minutes – no difference in outcomes

Beyond 75 minutes – significant reduction in 5 min Apgar Score

DDI

VS

BDI

Better correlation of

BDI with adverse

fetal outcomes

BDI Vs DDI

Irreversible Potentially reversible

Cord prolapse

Uterine rupture

Abruption

Failed instrumentation

Uterine hyperstimulation

Post epidural

Aortocaval compression

Approach to

bradycardia

Anything below 110 – abnormal

100-110 – borderline – postdates

Check – ensure it is not maternal HR and it has

normal baseline variability

Follow the 3 min rule

3 min rule

Time Action

3 Deceleration > 3 mins – emergency alarm

3-6 Reversible or non reversible?

Non reversible – Emergency delivery

Reversible – left lateral, stop oxytocin, tocolytic agent, fluids,

ephedrine

9 If no recovery – prepare for delivery

12 Must be in OT for delivery – instrumental/caesarean

15 Baby delivered

Take home message

BDI is essential, not DDI.

Determine cause of bradycardia – reversible or irreversible

Irreversible – BDI 15 mins

Reversible – intrauterine fetal resuscitation. “3 minute rule”

Self audit & set standards

THANK

YOU