No nationally recognized standard of care currently dictates the acceptable time interval to begin cesarean delivery. Previously, a 30-minute decision-to-incision interval was recommended. In studying this, Bloom and coworkers (2001) found that 69 percent of 7450 cesareans performed in labor commenced more than 30 minutes after the decision to operate. In a second study, Bloom and colleagues (2006) evaluated cesarean deliveries performed for emergency indications. They reported that failure to achieve a cesarean delivery decision-to-incision time of less than 30 minutes was not associated with a negative neonatal outcome. A subsequent systematic review echoed this inding (ToIcher, 2014). Despite this, when faced with an acute, catastrophic deterioration in fetal condition, cesarean delivery usually is indicated as rapidly as possible, and thus purposeful delays are inappropriate. he American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend that facilities giving obstetrical care should have the ability to initiate cesarean delivery in a time frame that best incorporates maternal and fetal risks and beneits.
Obtaining informed consent is a process and not merely a medical document (American College of Obstetricians and Gynecologists, 2015). The conversation should enhance a woman's awareness of her diagnosis and contain a discussion of medical and surgical care alternatives, procedure goals and limitations, and surgical risks. For women with a prior cesarean delivery, the option of a trial of labor should be included for suitable candidates. lso, in those desiring permanent sterilization or intrauterine device insertion, consenting for these can be completed concurrently.
n informed patient may decline a particular recommended intervention, and a woman's decision-making autonomy must be respected. In the medical record, clinicians should document her reasons for refusal and should note that the intervention's value and the health consequences of not proceeding with it have been explained.
For Jehovah's Witnesses, informed consent discussions regarding blood products ideally begin early in pregnancy. Acceptable blood products vary widely among individual women, and a preoperative checklist of approved products allows superior preparation (Hubbard, 2015; Husarova, 2016). In general, red cells, white cells, platelets, and plasma are viewed as primary blood components and are eschewed. However, certain clotting factors or cell fractions may be acceptable (Lawson, 2015). Before and after surgery, iron, folate, and, if necessary, erythropoietin are accepted agents to help maximize hemoglobin levels. Perioperatively, phlebotomy should be limited, and pediatric collection tubes are preferable. Intraoperative options include treatment of atony to limit blood loss; topical hemostatic agents, tranexamic acid, and desmopressin to promote clot formation; red blood cell salvage or acute normovolemic hemodilution to provide autologous donation; and controlled hypotensive anesthesia, uterine artery embolization, occlusive vascular balloons, and temporary aortic compression for uncontrolled bleeding (Belfort, 2011; vlason, 2015).
• Timing of Scheduled Cesarean Delivery
Adverse neonatal sequelae from neonatal immaturity with elective delivery before 39 completed weeks are appreciable (Clark, 2009; Tita, 2009). To avoid these, assurance of fetal maturity before scheduled elective surgery is essential as outlined by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) and discussed in Chapter 31 (p. 597). To assist with this and other components of cesarean delivery planning, the American College of Obstetricians and Gynecologists (2011, 20 14b) has created Patient Safety Checklists to be completed before the planned surgery.