CONTINUING MEDICAL EDUCATION

JPOG JAN/FEB 2015

Crash Caesarean Section

for Fetal Distress

5 SKP

Mak Shui Lam, MBBS, MRCOG, FHKCOG, FHKAM (O&G); Kou Kam On, MBBS, MRCOG, FHKCOG, FHKAM (O&G); Ng Ching Wah, RN, RNM, BHS (Nsg), MMid;
Leung Kwok Yin, MBBS, MD, FRCOG, FHKCOG, FHKAM (O&G)

INTRODUCTION
The rate of caesarean delivery for non-reassuring fetal heart tracing ranges from
2.9% to 4.6%1 and increases over the
years.2 A delay in delivery may thus result in hypoxic ischaemic encephalopathy, stillbirth, or neonatal death, depending on the severity and duration of fetal
hypoxia/acidosis.
When life-threatening fetal distress occurs, requiring immediate delivery by abdominal operation, this
type of emergency caesarean section
is referred to as crash caesarean section, as described by MacKenzie and
Cooke.3 It belongs to grade 1 emergency caesarean section according to
the classication system proposed by
Lucas et al.46 It is also the most urgent
type, based on the continuous spectrum suggested by the RoyalCollege
of Obstetricians and Gynaecologists.4
The rate of crash caesarean is estimated to be 0.60.7%.7,8
The classication system proposed

Crash Caesarean Section is the Most Urgent Type of Caesarean Section.

by Lucas et al categorizing the urgency

of caesarean section into four grades is

es and for better communication among

are to be taken care of? It is the aim

shown in Table 1. The Royal College of

medical staff.

of this article to review the risks and

Obstetricians and Gynaecologists advo-

However, crash caesarean sec-

benefits associated with crash caesar-

cates the recognition of a continuum of

tion is not without risks to the mother

ean sections, the alternative manage-

urgency in relation to levels of urgency

or even the baby. The question, then,

ment, and ways to achieve a swift and

for caesarean section, but agrees on the

is what is a reasonable duration for

safe delivery, as well as to explore the

idea that the four dened categories re-

decision-to-delivery interval (DDI) if

medicolegal aspect of the manage-

main useful particularly for audit purpos-

both the maternal and fetal well-being

ment of fetal distress.

37

38

CONTINUING MEDICAL EDUCATION

JPOG JAN/FEB 2015

rologic signs, and asphyxia lasting more

Table 1. Classification of Urgency of Caesarean Section6

than 12 minutes caused irreversible

brain damage and functional decits. To-

Description

tal asphyxia lasting for 12 to 13 minutes

Emergency caesarean section performed when there is

immediate threat to the life of woman or fetus

caused brain damage in primates, and if

Urgent caesarean section performed when there is maternal

or fetal compromise that is not immediately life-threatening

ten lead to the death of the fetus.15

Scheduled caesarean section performed when there is a

need for early delivery but no maternal or fetal compromise

cental abruption complicated by fetal

Elective caesarean section performed at a time that suits the

woman and maternity team

a DDI of 20 minutes was associated

Garde
1

lasting more than 20 minutes, it would ofIn humans, a study of severe plabradycardia by Kayani et al showed that
with substantially reduced cerebral palsy
and neonatal death rates than did a DDI
of 30 minutes.16 Similarly, neonatal and
maternal complications in uterine rup-

MATERNAL AND FETAL RISKS

DURING CRASH CAESAREAN
DELIVERY

tive assessment, review of preoperative

ture with complete fetal extrusion were

tests, and optimization of medical condi-

shown to be low with prompt intervention

tions (eg, eclampsia, adequate preoper-

in a study by Leung et al.17

The rate of complications in crash cae-

ative fasting, appropriate premedication,

In contrast, in a large series of

sarean deliveries has been observed to

and the explanation of anaesthetic risks

17,780 emergency caesarean sections

be higher than that in emergency or elec-

to patients).11 Furthermore, crash cae-

in a national cross-sectional survey in

tive caesarean deliveries. A retrospec-

sarean sections are required in cases of

England and Wales, although the odds

tive study showed that secondary acute

placental abruption, rupture of uterus, or

of an Apgar score < 7 at 5 minutes was

caesarean section following a failed vag-

eclampsia which by themselves carry a

signicantly higher with DDI > 75 min-

inal delivery was associated with more

greater risk of maternal complications

utes, the odds with DDI of 1675 min-

lacerations of the uterine corpus com-

and poorer fetal outcome.

utes, compared with that for DDI < 15

pared with primary elective caesarean

However, a study of a small series

minutes, was not signicantly different.13

section or primary acute caesarean sec-

from a university hospital concluded

More interestingly, a retrospective study

tion without any attempt to deliver vagi-

that emergency caesarean section per-

showed that very short DDI (below 20

nally. Blood loss greater than 1,000 mL

formed in the delivery room may result

minutes) was associated with lower um-

was also signicantly more frequent with

in a DDI of less than 30 minutes, with-

bilical blood pH or Apgar scores.7 There

secondary acute caesarean section.10

out detrimental perioperative effects

are four possible reasons to explain

When a caesarean section is performed

on mother or neonate.12 Another study

these paradoxical results. First, more

in haste by a less experienced doctor and

found that the maternal requirement for

critical conditions, like cord prolapse or

without gentle tissue handling, a greater

special care for a DDI < 15 minutes was

placental abruption, might have been

risk of laceration of the uterine corpus,

not statistically signicantly different from

managed with more urgent actions by

bladder, cervix/vagina, ligaments, and

that for a DDI of 1675 minutes.13

obstetricians. Less critical conditions

10

bowel may be expected. Chances of

might be due to a transient hypoxic ef-

trauma may increase when the baby is

FETAL RISKS WITH DELAYED

DELIVERY

skin lacerations, bone fracture, and birth

fect, which can improve spontaneously. Second, not all cases studied were

not delivered gently enough. Besides,

14

In experiments with rhesus monkeys,

life-threatening fetal distress. Third, fetal

crash caesarean section may leave too

an acute asphyxial episode of less than

encephalopathy may be present before

little time for anaesthetists to thoroughly

8 minutes might not cause brain dam-

labour but be manifested as intrapar-

perform all their tasks concerning preop-

age, an episode of more than 8 but less

tum fetal distress.18 Nevertheless, the

erative preparation, including preopera-

than 10 minutes produced transient neu-

action to expedite delivery in these crit-

CONTINUING MEDICAL EDUCATION

JPOG JAN/FEB 2015

ical conditions is still required to reduce

and Gynaecologists do not provide any

staff at one time without requiring them

further damage to the infant. Fourth, the

time duration constraint on performing

to reply; (3) dedicated operation theatre;

bradycardia-to-delivery

caesarean sections.

(4) providing adequate and trained man-

interval

(BDI),

23,24

which reects the actual duration of fe-

Each caesarean section should be

power during and after ofce hours; and

tal hypoxia, may be more relevant than

performed, considering its own merits

(5) providing general or regional anaes-

DDI in terms of neonatal outcomes.17,19,20

and individual circumstances.23 In cas-

thesia within 10 minutes.25

In a retrospective study of 106 cases of

es of severe fetal distress, caesarean

uterine rupture, signicant neonatal mor-

section should be initiated expeditious-

EXPERIENCE IN HONG KONG

bidity occurred when 18 or more minutes

ly in collaboration with anaesthetic and

A tertiary-wide audit on caesarean sec-

had elapsed between the onset of pro-

other necessary support personnel. In

tion for fetal distress was performed in all

longed deceleration and delivery.17 Be-

addition, reasons for delay should be

nine public hospitals with maternity units

sides, BDI, but not DDI, has been shown

documented in the chart by obstetrical,

in Hong Kong from April to June 1997.

to be inversely correlated with neurolog-

anaesthetic, and nursing personnel.24

Of the 243 cases audited, 42.8% of de-

24

ic outcomes and umbilical arterial pH at

The 30-minute time interval is only used

liveries were achieved beyond 30 min-

delivery.19,20 A retrospective study by Le-

as an audit standard and not as a basis

utes after decision of delivery. The main

ung et al reported that the median BDI in

for judging multidisciplinary team per-

reasons for the long DDI were related to

the group with irreversible causes of fetal

formance for any individual caesarean

preparation for operation (patient stabi-

distress was 5 minutes shorter than the

section.

lization, nursing procedures, obtaining

19

group with reversible causes, while its

Although the 30 minutes is consid-

consent, language barrier), not having

median DDI was only 1 minute shorter.20

ered an auditable standard, it may not

crash caesarean section, patient transfer to the theatre, availability of surgeon,

effective anaesthesia, and operation

Each caesarean section should be performed,

considering its own merits and individual
circumstances

theatre. After improvement measures in

various hospitals were instituted, a second audit in 2000 showed a reduction in
the proportion of deliveries with DDI >
30 minutes to 29.1% because of reduction of the rst three main reasons. About

RECOMMENDATIONS AND
GUIDELINES

always be achievable. MacKenzie and

80% of the DDI was used up before skin

Cooke concluded from their study that

incision. Difculty in dissection of the

The Royal College of Obstetricians

fewer than 40% of intrapartum deliveries

scar because of previous operation, or in

and Gynaecologists and the Ameri-

by caesarean section for fetal distress

delivery because of deeply engaged fetal

can College of Obstetricians and Gy-

were achieved within 30 minutes of the

head or macrosomia was encountered in

necologists recommend that obstetric

decision. The mean DDI for 22 crash

around 10% of cases.

services are to be capable of perform-

caesarean sections was 27.4 minutes.3

From July 2011 to December 2012

ing a caesarean section within a time

On the other hand, an audit conducted

in the public hospital Queen Elizabeth

interval of 30 minutes.21,22 A shorter

at a maternity hospital in Singapore from

Hospital, 94 cases of crash caesarean

time interval of 20 minutes is recom-

February 2003 to January 2004 found

section (1.01% of 9,352 delivery epi-

mended by the German Society for

that the mean DDI for crash caesarean

sodes) were performed for fetal distress,

Gynecology and Obstetrics.7 These two

section was 7.7 minutes, with 100% of

with 93.6% achieving a DDI of 30 min-

time standards are not supported by

25

deliveries made within 17 minutes.

utes. The mean DDI was 20 minutes.

any trials. On the other hand, the Soci-

These excellent results were achieved

There was only one case having an

ety of Obstetricians and Gynaecologists

by (1) following a strict protocol; (2) us-

Apgar score of < 7 at 5 minutes among

of Canada and the Royal Australian and

ing the public announcement system,

those with DDI > 30 minutes. There was

New Zealand College of Obstetricians

instead of paging, to alert all concerned

no signicant correlation between DDI >

39

40

CONTINUING MEDICAL EDUCATION

JPOG JAN/FEB 2015

Table 2. Indications for Crash Caesarean Section

not be exposed to iatrogenic injuries or

mistakes made because of carrying out
the procedure with too much haste.5

Fetal distress with severely abnormal fetal heart rate pattern such as
prolonged bradycardia
Umbilical cord prolapse
Placental abruption associated with abnormal fetal heart rate pattern
Abnormal pH 7.2 on fetal scalp blood sampling
Ruptured uterus
Severe antepartum haemorrhage associated with abnormal fetal
heart rate pattern

In high-risk cases, anticipation and

early detection of fetal heart abnormalities allow an earlier intervention for irreversible causes and a shorter BDI, which
may help improve fetal outcome. It would
also be advisable to have a crash caesarean protocol, communication protocols,
and regular crash caesarean section
drills with feedback to familiarize staff
with the workow.8,28,29 Using a multipha-

30 minutes and Apgar score < 7 at 5 min-

rst instead of crash caesarean section.

sic project of continuous quality improve-

utes (chi-square test; P = 0.621). There

For example, stopping oxytocin infusion

ment, a hospital has recently identied

was also no difference in cord blood pH

can help resolve hypertonic uterine con-

and overcome various systematic and

between DDI within and beyond 30 min-

tractions in the case of iatrogenic uterine

individual barriers, resulting in achiev-

utes (Student t test; P = 0.715). Detailed

hyperstimulation, and use of tocolyt-

ing the 30-minute standard.28 The nal

analysis of the time required in different

ics can also be considered; ephedrine

phase of this project involved making an

steps will be performed and reported

may be given to improve the maternal

overhead announcement of code green

elsewhere.

blood pressure in cases of regional an-

with room identication in the labour and

algesia-induced maternal hypotension

delivery unit whenever emergency cae-

CAREFUL SELECTION OF
CASES

if lateral positioning of the women and

sarean section was required because of

prophylactic intravenous hydration be-

fetal distress.28 This provided immediate

Crash caesarean section is indicated

fore administration of regional analgesia

attention and prioritization of the case,

in cases with immediate threat of fetal

are not effective enough. Amnioinfusion

rapid communication with anaesthetists

death. Reported indications included fe-

can be considered when cord compres-

and operating room staff, and arrival of

tal distress with severe fetal heart abnor-

sion is suspected in the presence of olig-

additional nursing personnel to transport

malities such as persistent bradycardia

ohydramnios and characteristic variable

the patient. The mean DDI dropped from

of more than 3 minutes, cord prolapse,

decelerations on fetal heart rate monitor-

40 minutes to 20 minutes.28 In another

fetal heart abnormalities associated with

ing are noted.

hospital, code red was used to facil-

27

placental abruption or severe antepar-

When an irreversible cause is iden-

itate communication between staff for

tum haemorrhage, pH 7.2 on fetal

tied or suspected, a caesarean delivery

emergency caesarean sections and to

scalp blood sampling, uterine rupture,

should be arranged urgently but not nec-

reduce the DDI.29 However, the authors

and bleeding from vasa praevia (Table

essarily in a crash manner, depending

concluded that restriction of indications

2).

on the clinical conditions of the fetus and

for colour code emergency caesarean

When fetal heart rate abnormalities

the woman. A proportion of emergency

sections is required to avoid unjustied

are detected, it is important to assess

caesarean sections do not have a clear-

maternal and fetal complication.29

and speedily search for the underlying

ly identiable risk factor for the need for

cause,26 preferably within 1 or 2 min-

emergency intervention.8,20

7,19,22,25

utes. When a reversible cause, includ-

The decision-to-delivery interval involves three steps: (1) preparation and

transfer of the patient to the operation
theatre; (2) induction of anaesthesia; and

post-regional anaesthesia, and aorto-

ACHIEVING SAFE AND QUICK

CRASH CAESAREAN DELIVERY

caval compression,26 is identied, in

During crash caesarean section for fetal

To shorten the time required for

utero resuscitation should be attempted

distress, the woman or her baby should

patient preparation in cases of crash

ing iatrogenic uterine hyperstimulation,

(3) skin incision to delivery of baby.

CONTINUING MEDICAL EDUCATION

JPOG JAN/FEB 2015

caesarean section, anticipating the possibility of emergency caesarean section

with earlier preparation involving blood
type and screen test, fasting, and optimization of maternal condition would be of
help. Epidural for pain relief can be considered so that a top-up can be offered if
emergency caesarean section is needed.
Having an experienced operating team
in-house has the advantage of allowing
intervention to take place within a shorter
period of time.30 Prophylactic antibiotic
usage can help offset infectious risk.12
Skipping the Foley catheter placement
can be done with minimal problems if
care is taken to avoid the bladder.31
Minimizing the transfer time to the
operating theatre is of importance. Hospital design should take into consider-

Cardiotocograph Showing Persistent Fetal Bradycardia Leading to Crash Caesarean

Section.

ation a short physical distance of the

operating theatre from the labour ward,

plications.12 Inside their delivery rooms,

epidural analgesia, are good alternatives

or having an operating theatre for cae-

a complete pack of sterile instruments,

to general anaesthesia in emergency

sarean section in the labour ward itself.

necessary anaesthetic equipments, and

caesarean setting, although general an-

Sayegh et al32 conducted a retrospec-

medications are available. However, the

aesthesia still seems to be the method of

tive study reviewing caesarean sections

operation was performed in suboptimal

choice for most anaesthetists in extreme-

performed in a French maternity hospi-

sterile conditions.12

ly urgent settings.36 An audit conducted

tal over a 6-month period. They found a

In the second step to minimize the

at a maternity hospital in Singapore from

mean DDI of 39.5 minutes for emergency

time for anaesthesia induction, it would

February 2003 to January 2004 showed

and urgent caesarean sections. The DDI

be best to have in-house anaesthetic

that the majority of patients (88.8%) had

was mainly inuenced by the time taken to

support. The American Society of Anes-

general anaesthesia for crash caesarean

get the patient into the theatre. The mean

thesiologists and the American College

section, while the rest had successful

decision-to-operating theatre interval ac-

of Obstetricians and Gynecologists sug-

epidural block extension. There was no

counted for 45.6% of the mean DDI in the

gest the availability of a licenced practi-

signicant difference in the DDI or mean

group. The authors highlighted the im-

tioner who is credentialed to administer

cord blood pH with respect to the type of

portance of reducing the decision-to-the-

an appropriate anaesthetic whenever

anaesthesia given. The authors suggest-

atre interval. Tuffnell et al stated that ap-

necessary.

ed that both general anaesthesia and

32

34

proximately 17% of caesarean sections

For the choice of anaesthesia, Dun-

extension of existing epidural block are

had a DDI exceeding 50 minutes, which

phy et al, in their article published in 1991,

acceptable modes of anaesthesia and

could be explained by delays in getting

suggested that regional blockade was

do not delay delivery of the fetus. The au-

the women into the operating room.33 As

associated with longer intervals than did

dit revealed that 100% of deliveries were

previously mentioned, Hillemanns et al

general anaesthesia. However, a more

achieved within the proposed 30-minute

showed that emergency caesarean deliv-

recent review by Dahl et al published in

DDI by implementing a protocol for crash

ery performed in the delivery room result-

2009 suggested that regional anaesthetic

caesarean sections.25

ed in a shortened DDI without detrimental

techniques, such as a single-shot spinal

perioperative maternal or neonatal com-

or a top-up of a well-functioning labour

35

In the third step to reduce the incision-to-delivery

time,

experienced

41

42

CONTINUING MEDICAL EDUCATION

JPOG JAN/FEB 2015

Suggested Measures for Achieving a Safe and Quick Crash Caesarean

Section

A single scalpel can be used for

incision in the skin and rectus sheath
during abdominal wound incision, thus
eliminating the time for changing scal-

Crash caesarean section protocol

Communication protocols

pels to gain entry into the abdomen. A

randomized controlled trial comparing

Good team work

Good collaboration with anaesthetists and staff of the operation
theatre

the use of one versus two scalpels in

Regular crash caesarean section drills

Multiphasic improvement project involving special coding

rate to be signicantly different.37 One

Educational programme for staff

Preparation of patient in labour and before operation
1. Anticipation of the possibility of deterioration in high-risk
cases, with early preparation of patient
2. Early detection of cardiotocographic pathology
3. Consideration of epidural for pain relief in labour
4. In-house support of senior obstetricians, midwives, and
anaesthetists with expertise in dealing with obstetric cases
5. Prophylactic antibiotic usage
6. Skipping Foley catheter placement
Patient transfer to operating theatre
1. Hospital design should take into consideration a short physical
distance of the operating theatre from the labour room
2. Consideration of having an operating theatre for caesarean
section in the labour room itself

patients undergoing elective general

surgery did not nd the wound infection
study showed that scalpels were sterile
after skin incision, supporting the view
that there is no need to discard the skin
scalpel to prevent wound infection.38 The
use of separate surgical knives to incise
the skin and the deeper tissues at caesarean section is not recommended by
the National Institute for Health and Clinical Excellence.5
Once the caesarean section surgery has started, surgeons should refrain from

diverting attention to con-

trol small bleeders or to repair visceral

lacerations. They can return to address
those surgical issues after delivery of

Induction of anaesthesia
1. In-house anaesthetic support
2. Regional anaesthetic techniques (eg, a single-shot spinal or a
top-up of a well-functioning labour epidural analgesia) as good
alternatives to general anaesthesia

the baby.

Incision-to-delivery interval
1. Involvement of experienced surgeons
2. Use of a single scalpel for incision in the skin and rectus sheath
during abdominal wound incision
3. Refraining from diverting attention to control small bleeders
or to repair visceral damage before delivery of the baby

Metzger et al,39 data on the uterine in-

The effect of duration of the interval from uterine incision to delivery

on fetal outcome seems to be unclear.
In a retrospective review by Maayancision-to-delivery interval of 855 cases
revealed that a uterine incision-to-delivery interval of > 2 minutes was associated with more feeding problems and
later hospital discharge compared with
a shorter interval of 2 minutes. Andersen et al40 studied 204 patients un-

surgeons should be assigned to per-

experienced surgeon should be pres-

dergoing caesarean delivery and found

form crash caesarean sections requir-

ent to supervise the performance of the

that, after correction for various factors

ing greater technical skills (eg, in cases

operation. An experienced surgeon is

(including fetal distress, meconium,

suspected to have dense intra-abdom-

expected to use less time for delivery

pre-eclampsia), uterine incision-to-de-

inal adhesions caused by previous

of the baby in these situations. Besides,

livery intervals did not signicantly

caesarean section or laparotomy, or in

the importance of surgical skills training

contribute to Apgar scores or umbilical

morbidly obese patients) or at least an

should be emphasized.

cord blood gases.40

CONTINUING MEDICAL EDUCATION

JPOG JAN/FEB 2015

RISK MANAGEMENT

principle and commitment to good and

cases of fetal distress. Placenta should

Prevention is better than cure. Peri-

evidence-based obstetric practice rath-

be sent for histopathologic investigation.

natal risk management using the con-

er than indulgence in defensive medi-

cept of foreseeability of harm, the

cine.42 However, most emergency cae-

CONCLUSION

harm in this case being fetal distress

sarean deliveries develop during labour

Crash caesarean delivery has always

or poor neonatal outcome, and pre-

in low-risk women and cannot be antici-

been considered as the immediate re-

vention of its development together

pated by prelabour factors.

sort to saving the fetus or mother when

with common sense can help improve

fetal outcome.

DDI is an important and integral

instrumental delivery is not achievable

part of critical conduct interval in acutely

or imminent delivery not expected. It is

The concept of foreseeability of

compromised fetus. Therefore, maternity

indicated in cases with immediate threat

harm, which forms the principle for safe

care units must possess full operational

of fetal death and when an irreversible

obstetric management, was introduced

strength to deliver appropriate care in

cause of fetal distress is identied. To

by Justice Benjamin Cardozo in 1916

acute emergencies. Pierre and Rudigoz43

achieve a swift and safe delivery with

and serves as a road map to obstetrics

suggested that a detailed analysis of ob-

crash caesarean section, numerous

malpractice lawsuits.41 In the case of

stetrical context and of each sequence of

measures could be taken into consider-

MacPherson vs Buick Motor Company,

the DDI is more efcient and realistic for

ation to reduce the time required (1) for

Justice Cardozo wrote that because

evaluation in medical liability cases than

preparation and transfer of the patient to

the operation theatre; (2) for induction of
anaesthesia; and (3) from skin incision

Crash caesarean delivery has always been

considered as the immediate resort to saving
the fetus or mother

to delivery of the baby. It is advisable to

have a crash caesarean protocol, good
team collaboration, and regular drills to
familiarize staff with the workow. Maternity care units must possess the capacity to perform crash caesarean sections

the danger is to be foreseen, there is

an optimal gold standard. In addition, it

within a 30-minute interval. It is prudent

a duty to avoid the injury . . . if [a per-

allows a prophylactic reection for a risk

to have good documentation of every

son] is negligent where a danger is to

management approach in each labour

case that could not reach the 30-min-

be foreseen a liability will follow. In the

ward.

ute target, and risk management should

42

the development

The National Institute for Health

always be considered for every case of

of fetal bradycardia serves as an indica-

and Clinical Excellence emphasized the

fetal distress. The shorter the DDI, the

tion to put the obstetrician on notice of

need to ensure safe birth of the baby in

more desirable it would be to achieve

acute fetal distress. Notice, in this exam-

as good a condition as possible without

this objective. BDI should also be kept

ple, refers to the circumstances in which

causing harm to the woman or her baby

to a minimum. Following the foreseea-

a physician or nurse has sufcient time

through iatrogenic injury or mistakes

bility-of-harm principle and anticipating

to identify the potential for acute fetal

made because of carrying out the proce-

the possibility of deterioration in high-

distress and an ample opportunity to

dure with too much haste.5 The balance

risk cases, together with commitment to

correct or prevent the problem through

between swift and safe delivery should

evidence-based obstetric practice, can

timely intervention. The legal test would

always be kept in mind. When DDI is

help improve fetal outcome in cases of

then be one based on what a reason-

more than 30 minutes, good documen-

fetal distress.

ably prudent obstetrician/nurse would

tation of reasons and fetal condition be-

foresee and would do in light of [that

fore operation may help diminish prob-

information] under the circumstanc-

lems of medicolegal concern. It would be

es.42 Present-day concerns should be

prudent to document arterial and venous

focused on the foreseeability-of-harm

cord blood pH and base excess for all

example by Phelan,

42

About the Authors

Dr Mak is Resident, Dr Kou is Associate Consultant, Ms Ng is
Advanced Practice Nurse, and Dr Leung is Chief of Service, in
the Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong.
A list of references can be obtained upon request to the editor.

43