CLINICAL ARTICLE The effect of time intervals on neonatal outcome in elective cesarean delivery at term under regional anesthesia Ayala Maayan-Metzger a, ⁎, Irit Schushan-Eisen a , Liat Todris b , Abba Etchin c , Jacob Kuint a a Department of Neonatology, Edmond and Lili Safra Children's Hospital, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv University, Israel b General Intensive Care Unit, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv University, Israel c Department of Anesthesiology, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv University, Israel abstract article info Article history: Received 28 April 2010 Received in revised form 1 July 2010 Accepted 23 August 2010 Keywords: Cesarean delivery Neonatal outcome Time intervals Objectives: To measure 3 intervals of time—induction of regional anesthesia to delivery (I–D), initial skin incision to delivery (S–D), and uterine incision to delivery (U–D)—in elective cesareans and to evaluate the impact of the duration of these 3 components on short-term neonatal outcome. Methods: We reviewed retrospective data on the duration of the components from the computerized database of the obstetrics operation room at the Sheba Medical Center, Tel Aviv, Israel, and from the medical records of term neonates. Results: Sufficient data were available in 933 cases. The parameters associated with longer time to delivery at any stage were epidural rather than spinal anesthesia, maternal diabetes, previous cesarean delivery, antihypertensive treatment, higher birth weight (3456 g and 3285 g for U–D interval longer than 2 minutes and U–D interval up to 2 minutes, respectively; P = 0.02), and male fetus. The duration of the I–D, S–D, and U–D intervals had no significant impact on any of the measured neonatal parameters. Conclusion: With regard to neonatal wellbeing, obstetricians have a relatively large safety margin in the time taken for inducing regional anesthesia and making the first and uterine incisions. © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction Cesarean deliveries account for 20%–25% of all births in Israel and N 30% of all births in the USA [1]. Many cesarean deliveries are elective because of, for example, previous cesareans, multiple pregnancies, breech presentation, large fetal weight estimates, maternal medical conditions, and maternal request. Anesthesia for elective cesarean delivery is mostly regional (epidural or spinal). Several studies have shown that respiratory distress is more common among infants delivered via cesarean with general anesthesia than among those delivered vaginally [2–6], but cesarean delivery under regional anesthesia is considered to be of low risk for the newborn and does not require the attendance of a pediatrician [7]. However, it is commonly believed that cesarean delivery is stressful for the fetus and that taking as little time as possible to accomplish the procedure is likely to enhance the infant's wellbeing after delivery. An uneventful cesarean delivery at term can be divided into 3 main components for the purposes of measuring the duration of the entire procedure: from induction of regional anesthesia to delivery (I–D); from incision of the skin to delivery (S–D); and from incision of the uterus to delivery (U–D). Previous studies have shown that cesarean delivery under general anesthesia results in shorter I–D intervals compared with cesarean under regional anesthesia [8–10] and that the U–D interval is longer in cases of breech presentation than in cases of vertex presentation [8]. Assuming that longer duration of any or all of the elements of the procedure might affect neonatal wellbeing, several studies investigated the relationships of these measurements with fetal cord pH and Apgar score [8–13]. The results were incon- clusive, although some studies defined safe intervals as being up to 30 minutes for I–D and 90–180 seconds for U–D [9,10,12]. The aim of the present study was to measure the I–D, S–D, and U–D intervals and to characterize the predisposing risk factors for short- term neonatal outcome (5-minute Apgar score b 7, pediatrician attendance, respiratory distress, cyanotic events, meconium-stained amniotic fluid, feeding intolerance, hypoglycemia, jaundice, and age of ≥5 days at hospital discharge); furthermore, we aimed to evaluate the impact of the duration of each component on the short-term outcome of singleton full-term infants. 2. Materials and methods The study included data for neonates and their mothers who gave birth at the Sheba Medical Center, Tel Aviv, Israel, between May 1, 2006, and July 31, 2007. There are approximately 10 000 deliveries per year at the study center. Women who gave birth to singletons at term (gestational age 37–42 completed weeks) via elective cesarean with regional anesthesia (either spinal or epidural) during the study period were included. Exclusion criteria were multiple pregnancies International Journal of Gynecology and Obstetrics 111 (2010) 224–228 ⁎ Corresponding author. Department of Neonatology, Sheba Medical Center, Tel Hashomer 52621, Israel. Tel.: +972 3 5302424; fax: +972 3 5302215. E-mail address: maayan@post.tau.ac.il (A. Maayan-Metzger). 0020-7292/$ – see front matter © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2010.07.022 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo