Adherence to Intravenous Access Recommendations for Cesarean Delivery

Cesarean delivery is the most commonly performed surgery worldwide.1 Blood loss associated with cesarean delivery may be substantial and is the leading driver of parturient morbidity and mortality.2 Given this, intravenous (IV) access sufficient to permit intraoperative resuscitation and blood transfusion is necessary for safe parturient care.3 We assessed adherence to recommendations for minimal IV access for cesarean delivery and characterized patterns of adherence according to patient demographics and medical risk factors for severe blood loss.We reviewed medical record data for all patients undergoing cesarean delivery on the labor and delivery unit of one urban academic hospital between April 1, 2023, and September 5, 2023. At our institution, labor and delivery nurses place the majority of IV catheters, with a catheter size of 20-gauge or larger considered to be acceptable. We excluded patients younger than 18 yr old, with pre-existing central venous access, and with missing data on IV size. We also excluded patients with missing data on IV placement time relative to surgery start since we could not determine whether IVs were placed pre-operatively in these patients. The University of Pennsylvania (Philadelphia, Pennsylvania) Institutional Review Board deemed this study exempt from human subjects’ review.Based on available guidance from United States professional societies,3 we defined venous access of at least one 18-gauge catheter or two or more 20-gauge catheters at the time of incision as meeting recommendations; access equal to or less than one 20-gauge catheter was considered to not meet recommendations. We collected additional information that we hypothesized might influence level of IV access including patient demographics; medical and pregnancy history; American Society of Anesthesiologists (ASA; Schaumburg, Illinois) Physical Status at admission; IV substance abuse history; cesarean section urgency;4 and other procedure factors. We used a published tool to stratify patients into low, medium, and high risk of hemorrhage based on preoperative data.5 We used descriptive statistics to characterize patients with versus without recommended venous access and used exploratory multivariable logistic regression to measure the effects of patient and procedure-level factors on this outcome. Adjusted results for all covariates in the model are reported. We estimated a priori that approximately 400 cesarean deliveries would provide sufficient power to identify associations between the outcome and common risk factors at an odds ratio of at least 1.5; as such, we reviewed 501 consecutive cases, anticipating that 80% (i.e., 400 cases) would be eligible for inclusion. We used P < 0.05 for statistical significance. We confirmed goodness-of-fit of our regression model using the Hosmer-Lemeshow chi-squared test. Interactions were not assessed. Analyses were performed using Stata 17.0 (Statacorp, USA).After exclusions, our sample included 465 patients undergoing cesarean delivery. A total of 303 patients (65.2%) had IV access meeting or exceeding recommendations; 162 (34.8%) had less access than recommended (table 1). There were no patients in the final sample with an ASA Physical Status score of 4 or higher on admission or with a documented history of IV substance abuse. After adjustment (table 2), the odds of receiving a recommended level of IV access was lower for black versus white patients; (odds ratio, 0.38; 95% CI, 0.22 to 0.68, P = 0.001); non-English versus English speakers (odds ratio, 0.31; 95% CI, 0.13 to 0.72; P = 0.006); and patients with longer versus shorter length of hospitalization prior to cesarean delivery (odds ratio, 0.86; 95% CI, 0.78 to 0.96; P = 0.006). Odds of receiving a recommended level of IV access was higher for patients with versus without diabetes (odds ratio, 2.03; 95% CI, 1.06 to 3.90; P = 0.03) and those undergoing stat cesarean delivery (i.e., to address an immediate threat to parturient or fetal life) versus elective cesarean delivery (i.e., timing arranged to suit the parturient and clinical team odds ratio, 3.29; 95% CI, 1.03 to 10.47; P = 0.04). Other factors, including body mass index, estimated postpartum hemorrhage risk, and onset of labor prior to cesarean delivery, were not associated with IV access level.Among 465 cesarean deliveries performed at one large academic hospital, one in three cases were performed with IV access below recommended levels. Black patients, non-English speakers, and patients admitted for longer versus shorter durations prior to their cesarean delivery experienced greater risk of undergoing surgery with less IV access than recommended. Patients with diabetes were more likely to have recommended levels of IV access, perhaps due to an institutional policy requiring placement of dedicated IV catheters for insulin infusions. In addition, those undergoing cesarean deliveries under the most emergent circumstances were more likely to have recommended IV access, perhaps as a response to clinical acuity. Gaps in adherence to IV access recommendations may be due to a higher likelihood of difficult access in certain populations6,7 or excessive reliance on pre-existing, small-gauge access for patients hospitalized prior to cesarean delivery. Since we collected data from one center, our results may not be applicable to other institutions or clinical contexts. Observed associations between parturient primary language spoken and IV access may be influenced by the relatively small number of non-English speakers. Likewise, there were no patients with ASA physical status of 4 or higher on admission or patients with a documented history of IV substance abuse in our final study sample. Validation of our findings in a larger multi-institutional cohort would provide insight into study generalizability. It is also possible that providers’ decisions regarding IV placement were influenced by clinical factors not captured in the study database. Nonetheless, our results highlight opportunities to improve adherence to IV access recommendations for cesarean delivery; efforts to improve such adherence should focus first on reducing differences in IV use patterns across demographic groups and ensuring that plans for IV access incorporate information on postpartum hemorrhage risk. Appropriateness of venous access for cesarean delivery may serve as a potential quality measure that indicates safety, equity, and interdisciplinary team performance.The authors declare no competing interests.