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Abstract

Background:

Cesarean delivery surgical quality indicators and outcomes support the surgical skills of family medicine physicians. These data have educational and clinical implications yet are largely unexplored. Our study updated cesarean surgical times, incision-to-delivery time, and neonatal Apgar scores from a midwestern family medicine residency program.

Methods:

All cesarean deliveries performed by family medicine faculty from January 2012 to March 2021 were reviewed. Total surgical time, incision-to-delivery time, Apgar scores at 1 and 5 min, and maternal demographic information were recorded.

Results:

320 cesarean deliveries were reviewed. The average total surgical procedure time was 64.3 min (SD = 17.9) and incision-to-delivery time was 9.5 min (SD = 4.9). The average 1-min Apgar score was 7.5 (SD = 1.8) and the average 5-min Apgar score was 8.7 (SD = 1.0). There were no significant correlations between 1- and 5-min Apgar scores and procedure times.

Conclusion:

Cesarean delivery quality indicators from family medicine faculty are updated and appear similar to those reported previously in studies that did not include the presence of learners. This EMR-based study provides baseline information for future surgical cesarean delivery quality improvement and outcomes research.

Keywords

cesarean delivery cesarean section total surgical procedure time incision-to-delivery time Apgar scores

Introduction

Family medicine physicians are critical for the continued delivery of obstetrical services in many communities, particularly in “obstetrical deserts” in the United States (US).^1,2 In 2021, 57.3% of family medicine physicians who performed cesarean deliveries were in rural US communities, and 38.6% provided cesarean deliveries in counties without any obstetrician/gynecologist.¹ This trend has only continued to progress.³ As policymakers in the US struggle with this increasing health disparity, it is evident that the adequate training of the family physician workforce during residency will be key to the acquisition of robust operative skills to ensure optimal cesarean maternal and neonatal outcomes.^1,2,4,5 Such training may be even more critical in midwestern states that are largely rural.¹

Cesarean deliveries are commonly performed in the US by physicians trained in this type of surgery, including family medicine physicians.⁶ Cesarean delivery outcomes are typically categorized into maternal or neonatal outcomes. Maternal outcomes can be affected by individual patient factors, as well as surgical quality indicators such as procedure time. Surgical time is often prolonged due to a wide variety of operative and patient factors.⁷ Total time under anesthesia during surgery may have a significant impact on maternal outcomes.⁸ The initial portion of the cesarean delivery surgery, from the skin incision to the delivery of the neonate, is referred to as “incision-to-delivery time” and is emerging as a critical metric that may have a significant impact on long-term neonatal outcomes.⁹ Even a 1- to 2-min delay in neonatal delivery time may be associated with potential lifelong adverse health outcomes.¹⁰

Maternal and neonatal health outcomes are often independent of each other, but both may be associated with cesarean delivery times. One neonatal outcome, the Apgar score, has been commonly used as a global standard outcome measure of cesarean deliveries.^11,12 Neonates with a skin (incision)-to-delivery time greater than 3 min were about 4 times more likely to have a low Apgar score than those who were born when skin incision-to-delivery time was less than 3 min. The risk of long-term adverse health consequences makes it imperative to reduce factors associated with low Apgar scores at 1 and 5 min, including incorporating best practice in obstetric anesthesiology, continuously monitoring the fetus, avoiding fetal cardiac abnormalities, improving surgical techniques, and decreasing incision to delivery time in maternal patients who have a higher body mass index, a repeat cesarean delivery, or a prolonged second stage of labor.^8,10,13

All cesarean delivery outcomes can be associated with cesarean delivery quality indicators. However, there are few studies from the US detailing surgical delivery times for family medicine providers. In a 1995 study, the average total cesarean procedure time was found to be 63.1 min for all family physicians, with 1-min Apgar scores 14.1% lower and 5-min Apgar scores 2.9% lower than published standards.⁴ A 2013 study updated the information for cesarean delivery outcomes for family medicine providers, focusing on a comparison of cesarean delivery outcomes (maternal and neonatal) for rural family physicians and obstetricians along with cesarean delivery surgical quality indicators.¹⁴ For neonates delivered by family medicine providers, the Apgar scores were found to be 8.0 ± 1.8 at 1 min and 8.7± at 5 min, with no difference in the score between family medicine and obstetricians. This study noted a total surgical time of 55.2 ± 14.7 min for family medicine, which was statistically significantly shorter than 42.5 ± 42. 5 min reported by obstetricians and was the only cesarean delivery quality indicator that was different between the 2 groups of surgeons.¹⁴

Neither of these studies included learners. The only study we found that included family medicine residents in their data was a 2006 study that investigated cesarean deliveries performed by residents within a family medicine training program. They found an average operative time of 43 min and indicated that 12 of 277 infants had 1-min Apgar scores <5, and 1 had a 5-min Apgar score <5.¹⁵ A detailed search of the databases common in medical sciences (Embase, Medline, PubMed, Scopus, and Web of Science)¹⁶ with the MeSH terms family medicine cesarean sections, cesarean section quality indicators, surgical times, newborn outcomes, and Apgar score, did not yield any additional studies that provided total cesarean procedure times or incision-to delivery times.

The purpose of our study was to explore the surgical quality indicators, as measured by procedure times, as well as neonatal outcomes, represented by 1- and 5-min Apgar scores of cesarean deliveries performed by family medicine faculty physicians in conjunction with family medicine residents. Our hypothesis was that the total procedure time for family medicine physicians for a cesarean delivery would have remained the same or improved since 1995 and that the Apgar scores would be the same or improved over the past decade from that previously reported a decade ago.¹⁴

The specific aims of this study were to (1) Update surgical procedure times for cesarean deliveries that would include total surgical time, skin incision-to-delivery time, and neonatal delivery to end-of-procedure time, (2) Quantify neonatal Apgar scores at 1 and 5 mins, and (3) Determine if there is any statistical correlation of surgical procedure times, particularly incision-to-delivery time, with Apgar scores at 1 and 5 min.

There is a lack of information about total cesarean procedure time for family medicine physicians for the past decade and none that included incision-to-delivery times that are likely to impact neonatal outcomes. There is also an absence of information regarding how the presence of family medicine residents impacts surgical quality outcomes in cesarean deliveries. Residents graduating from our family medicine training program have a historically high likelihood of entering rural obstetrical practice, making this kind of information and training very likely to be used clinically in the future.

Methods

Study Design

This was a retrospective review of electronic medical records. The study was approved by the Institutional Review Board (IRB #0602-22-EP).

Study Population

All cesarean deliveries performed by teaching faculty from the family medicine residency training program at 1 midwestern urban academic medical center from January 1, 2012 through March 15, 2021 were included. Twin or multiple gestational pregnancies were excluded from the study.

Study Setting

This is a large family medicine residency program located in a medium-sized city in a primarily rural, midwestern US state. At the time of the study, 8 attending family physicians performed routine cesarean deliveries with family medicine residents and medical students in attendance, and none excluded learners. There were no obstetrics-fellowship-trained family medicine faculty, and all faculty have been in academic practice for over a decade. There is no obstetrics fellowship for family medicine residents on site. Residents are available for all operative procedures. They are typically involved in making surgical incisions and delivery of the neonate and may be the first assistant.

Outcome Measures

Maternal demographic variables of age, race and ethnicity, gravida, and parity were recorded. Surgical time was noted in minutes and divided into total surgical time and 2 partial times of (a) incision-to-delivery time and (b) neonatal delivery time to closure of incision.

Neonatal Apgar scores at 1 and 5 min were recorded by the nursing staff. There are 5 parts to an Apgar score: color, heart rate, reflexes, muscle tone, and respiration. Each category is weighted evenly and assigned a 0, 1, or 2 value. About 1 and 5 min after birth, the component scores are summed and recorded. A score of 7 to 10 is considered reassuring, a score of 4 to 6 is moderately abnormal, and a score of 0 to 3 is deemed low in full-term and late preterm infants.⁶

Statistical Analysis

All data analyses were performed using SPSS v28.0. Descriptive statistics were used to summarize the data for the sample. Total and partial procedure times were quantified in minutes. Pearson’s correlation was used to determine the relationship between 1- and 5-min Apgar scores and procedure times.

Results

The final study group included 320 cesarean delivery procedures with an average maternal age of 28.0 (SD = 5.3) years and an average gestational age of 274.1 days (SD = 9.0; Table 1). The average gravidity was 2.5 (SD = 1.6) and average parity 1.8 (SD = 1.3). The most common subgroup was primigravida (n = 113). Less than 25% of subjects reported being Hispanic or Latino and 61.3% were white. The average total surgical procedure time was 64.3 min (SD = 17.9). The average time from surgical incision-to-delivery was 9.5 min (SD = 4.9). The average 1-min Apgar score was 7.5 (SD = 1.8) and the average 5-min Apgar score was 8.7 (SD = 1.0). There were no significant relationships between 1- and 5-min Apgar scores and procedure times (Table 2).

Table 1.

Description of the Sample (n = 320).

Age in years (mean, SD)	28.0	5.3
Ethnicity (n, %)
Not Hispanic or Latino	241	75.3
Hispanic or Latino	75	23.4
Unknown/refused	4	1.3
Race (n, %)
White or Caucasian	196	61.3
Black or African American	35	10.9
Asian	15	4.7
Hispanic	5	1.6
Native Hawaiian or other Pacific Islander	1	0.3
Other	61	19.1
Unknown/refused	7	2.2
Gestational age (days) (mean, SD)	274.1	9.0
Gravidity (mean, SD)	2.5	1.6
Gravidity (n, %)
1	113	35.3
2	79	24.7
3	57	17.8
4	40	12.5
5	17	5.3
6 or more	14	4.1
Parity (mean, SD)	1.8	1.3
Parity (n, %)
0	18	5.8
1	153	49.2
2	71	22.8
3	39	12.5
4	23	7.4
5	3	1.0
6 or more	4	1.2
Incision to delivery (min) (mean, SD)	9.5	4.9
Delivery to procedure finish	54.9	15.9
Incision to procedure finish (min) (mean, SD)	64.3	17.9
Apgar-1 (mean, SD)	7.5	1.8
Apgar-5 (mean, SD)	8.7	1.0

Table 2.

Relationships Between Neonatal 1- and 5-min Apgar Scores and Surgical Cesarean Delivery Procedure Times.

Minutes of time	1-min Apgar score		5-min Apgar score
Minutes of time	r_s	P-value	r_s	P-value
Difference between “incision to delivery” time	−0.05	.458	−0.08	.212
Difference between Total cesarean procedure time	−0.04	.560	−0.04	.460

Discussion

Our study updates previous information regarding cesarean delivery procedure times (average 64.3 min), incision-to-delivery (9.5 min), and Apgar scores (average Apgar score 7.5 at 1 min and 8.7 at 5 min) for procedures performed by faculty and residents at a single midwestern family medicine residency program. The majority of the patients were white, under the age of 30 years, primigravid, and, on average, over 39 weeks of gestational age. We hypothesized that the average total procedure time for cesarean delivery would remain the same or decrease from earlier studies. The average total procedure time in our study was slightly higher than that reported nearly 30 years ago in 1995 (63.1 min).⁴ While a shorter average total procedure time (55.2 min) was seen in a 2013 study, a decade later we report total procedure times that are more in keeping with the 1995 report.¹⁴ This may be attributable to the surgical training time with learners. The 1995 and 2013 studies did not include learners, and surgical training may result in the prolongation of surgical time.¹⁷ Adequate time for training in surgical techniques is essential for family medicine physicians to be able to perform cesarean deliveries,^11,17 particularly for rural areas that often rely on family medicine physicians to provide obstetric care.

While we hypothesized that modern Apgar scores would be the same or higher than previous studies, our average 1-min Apgar score (7.5) is lower than that reported in the 2013 study (8.0).¹⁴ However, 5-min scores were identical (8.7) for family medicine physicians in both studies. Both 1- and 5-min Apgar scores would be considered “reassuring.”⁶ We did not find any statistical correlation between times for the surgical procedures, particularly incision-to-delivery time, with the Apgar scores at 1 or 5 min. This finding may support the assertion Apgar scores are a nonspecific marker of illness and 1-min Apgar scores, in particular, are poor predictors of long-term outcomes.^18
-20 The change from 1- to 5-min scores, and 5-min scores are better predictors.¹⁸

There is some evidence that the duration of the procedure may also have little impact on overall neonatal outcomes. The 2013 study of surgical cesarean delivery times indicated that, while the average total surgical procedure time varied by 13 min between family medicine and obstetric physicians, there were no significant differences in any of the neonatal outcomes (Apgar scores, length of hospital stay, transfer to neonatal intensive care unit, fetal death, or readmission).¹⁴ In that study, maternal intraoperative complications and infectious complications were also statistically equal between deliveries performed by family medicine and obstetric physicians. Curiously, cesarean deliveries performed by obstetricians were shorter on average, but they had statistically higher levels of postoperative complications. Deliveries performed by family medicine physicians resulted in significantly longer hospital stays (3.0 days vs 2.6 days).¹⁴

Overall, our study indicates that examination of surgical delivery metrics and outcomes is important, but it is evident that the impact of surgical quality indicators currently in use for cesarean deliveries may need to be reassessed. The importance of such studies is likely to grow and become more critical as tracking is enhanced by technology, bioinformatics, and artificial intelligence additions to electronic medical records (EMRs). We anticipate further studies will include comprehensive and individualized surgical analysis as well as maternal and fetal factors and outcomes. They should also account for the role and level of involvement of the learners during the procedures. One such surgical group is piloting an interactive software platform at their institution that provides surgeons with real-time updates for individualized clinical, financial, and patient-reported outcomes using EMRs.²¹

Our study has limitations. Missing data is a common limitation in EMR-based research. Additionally, characteristics of the surgery and physicians (training and number of cesarean deliveries performed by the teaching faculty physicians or learner) and patient factors (history of previous cesarean deliveries and premorbid health risk factors) could not be accounted for. Maternal chart reviews often have incomplete information and do not include all maternal or newborn information, such as readmission or transfer outside the system to other hospital or neonatal units, and access to neonatal information is restricted if the obstetrician from the primary care provider is not the pediatric provider.¹⁴ We did not look at whether the case was urgent, emergent, or a scheduled section. For emergent sections specifically, the longer it takes to deliver the infant the worse the outcomes are expected; future studies should examine differences based on reason for the cesarean section. The surgical times in our study do not detail the form or time of involvement in the procedure by the learners. The relationship between the level of involvement of the learner in cesarean deliveries and maternal and neonatal outcomes should be explored further. Our study is also limited by the fact that it took place at 1 urban institution and may not be representative or generalizable to other family medicine training sites. The 2013 data we used for comparison to our findings was gathered from rural locations; there may be factors specific to rural sites that affect any differences between the 2013 data and our findings.

Conclusion

Results from this study yield updated surgical quality indicators for cesarean delivery performed by family medicine faculty in conjunction with learners. Surgical times and neonatal Apgar scores are provided and include incision-to-delivery time, which was not correlated with Apgar score at 1 or 5 min. The total surgical time was similar to that noted in 1995⁴ and longer than in 2013,¹⁴ but previous studies of family medicine physician-led cesarean deliveries did not include learners. Apgar score at 5 min was unchanged from previous studies.^4,14,15 These results are likely secondary to learner presence, but the lack of correlation of incision-to-delivery surgical time with the Apgar score suggests that surgical time may not impact neonatal outcomes. This EMR-based study provides baseline information for family medicine providers of cesarean deliveries for future surgical cesarean delivery quality improvement and outcomes research.

Footnotes

Frauke Wilcox and Mary Beth Steele for administrative assistance.

Author Contributions

Jeremy King,Birgit Khandalavala,Jenenne Geske,and Chanont Sricharoen designed the study. Jeremy King and Birgit Khandalavala wrote the first draft of the manuscript. Jenenne Geske revised the article and analyzed the data. All authors approved the final version.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) received no financial support for the research,authorship,and/or publication of this article.

Ethical Approval

This was a retrospective review of electronic medical records. The study was approved by the Institutional Review Board (IRB #0602-22-EP).

ORCID iD

Birgit Khandalavala

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A Study of Cesarean Deliveries From a Single Midwestern Residency Program: Total Surgical Time,Incision-to-Delivery Time,and Neonatal Apgar Scores