June 22, 2023

Standardizing the Decision-to-Incision Process Improves Fetal Outcomes After C-Sections


New research out of Boston Medical Center hopes to set a more equitable standard of care and improve communication among labor and delivery teams.

The Bottom Line

New research from Boston Medical Center shows that implementing a standardized process for cesarean deliveries, or C-sections, performed out of concern for the fetus significantly improved outcomes, increasing the rate of healthier babies immediately postpartum, particularly for Black and Latino/a infants.


There is currently a recommended time of 30 minutes from the decision to perform a cesarean to the first incision (decision-to-incision time or DIT) for emergent deliveries. However, there is little guidance on how to achieve this goal, and there is no current recommended time for “urgent” (but not emergent) deliveries. This quality improvement intervention is the first to designate and implement “urgent” delivery criteria to reduce DIT for these cesarean deliveries and evaluate if a standard algorithm for urgent cesarean deliveries was associated with improvement in clinical outcomes. In this study, “urgent” was defined as no cervical change after a dilation of 6 cm and slightly abnormal changes in the fetal heart rate, like bradycardia with variability or tachycardia.

Prior to this research, there was no data on the effects of decreasing DIT on maternal and fetal outcomes.

Study Objective

To create a standardized pre-procedure process for urgent cesarean deliveries to decrease the time from making the decision to deliver by cesarean (as opposed to a vaginal birth) to beginning the surgical process.

The Details

The BMC Labor & Delivery team decreased DIT for people with critical conditions through a series of improvements in staff coordination and operating room team function. One of the most important steps was creating a workflow triggered by certain patient conditions, and it involved many simulations to see what process made sense and worked best.

Researchers analyzed 642 urgent cesarean deliveries — 199 pre-implementation and 160 post-implementation of the new standardized algorithm. Data was stratified by race and ethnicity at all stages to account for racial bias and inequities.  


The changes in timely care were associated with improvements in infant Apgar scores for patients who delivered by cesarean section due to concerning fetal heart rates. The researchers highlight that those findings were most significant for Black and Hispanic patients.

Post-implementation of the standardized algorithm, the overall mean decision-to-incision time improved from 88 to 50 minutes. When broken down by race and ethnicity, the mean decision-to-incision time among Black non-Hispanic patients improved from 98 minutes to 50 minutes. Among Hispanic patients, it improved from 84 minutes to 49 minutes.

Pull Quote

“These changes should help L&D units decide which cases need to be prioritized, especially if there is more than one cesarean to complete,” said senior author Ronald Iverson, MD, MPH, an obstetrician gynecologist and director of Quality and Safety for OBGYN at Boston Medical Center in a recent press release. “These findings also suggest that clear, objective indications and expectations for treatment may be the first steps to eliminating biases in how we care for people.”


Tibavinsky Bernal L, Yarrington CD, Xuan Z, Zani L, Friedman S, Schultz M, Chandra P, Iverson RE. (2023). “Decreasing Decision-to-Incision Times for Unscheduled, Urgent Cesarean Deliveries” Obstetrics & Gynecology.

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