Clinical implications
We observed a significant increase in compliance with the protocol for red code cesarean sections to reach full compliance in 2018 (p = 0.0020). However, despite better compliance with the decision-delivery interval imposed by the protocol, there was no significant difference in neonatal morbidity. This is in accordance with a literature review by Pierre and al. who report that the pathology leading to emergency cesarean section outweighs the neonatal prognosis over the mere adherence to a short decision-delivery interval (15).
While there was no significant difference in neonatal mortality outcomes in our population overall in terms of compliance with the protocol, there appeared to be a trend towards a decrease in the number of newborns with an arterial pH of less than 7 at birth, an Apgar score of less than 7 at 5 minutes of birth, and neonatal deaths between 2015 and 2018. It can then be assumed that adherence to the protocol leads to a decrease in the number of cases of neonatal asphyxia. This lack of significance of the results can be explained by inadequate power of our study to demonstrate this point. It would therefore be interesting to conduct a study with higher numbers to confirm this hypothesis.
Our study revealed that some indications of non-elective cesarean sections did not appear in the protocol. These non-protocol indications included preeclampsia, HELLP syndrome, intrauterine infection, and maternal shock, pathologies which don not necessarily require a cesarean section depending on the severity of the pathology. This underlines one of the limitations of the protocol in that a specific color code is not always adequate. It is important thus to remember that while such a protocol assists decision making in current practice, it is crucial to adapt management to each clinical situation for optimal outcome.