The anesthesia-to-incision interval accounts for most of the observed difference in decision-to-delivery time between urgency categories during emergency cesarean delivery: a single-center retrospective cohort study

Objective Decision-to-delivery interval (DDI) is widely used to audit emergency cesarean delivery, but total DDI does not distinguish workflow performance from risk-based clinical decisions. This exploratory study compared DDI between urgency categories and quantified the contribution of individual process components to the observed difference. Methods This single-center retrospective cohort study included 80 category I or II emergency cesarean deliveries between March 1, 2024, and October 31, 2025. DDI was divided into five mutually additive intervals. Between-category mean differences and component contributions were estimated using 50,000 stratified bootstrap resamples. Anesthesia type was considered a potential process-pathway variable because urgency may influence anesthetic strategy, which may in turn affect pre-incision workflow and total DDI. Results Median DDI was 18.0 min, and 78 cases (97.5%) achieved delivery within 30 min. Median DDI was shorter in category I than category II cases [14.0 (10.0–16.0) vs. 19.0 (17.0–23.0) minutes; P < 0.001]. The reconstructed mean difference was 6.31 min (95% bootstrap CI, 3.85–8.73). The anesthesia-to-incision interval differed by 5.24 min (95% CI, 4.04–6.39) and accounted for 83.1% of the observed mean difference. General anesthesia was used in 73.7% of category I cases and 8.2% of category II cases. In the primary model adjusted for shift and major indication, category II urgency was associated with a 6.55-minute longer DDI (95% CI, 3.86–9.25). Conclusion Most emergency cesarean deliveries met the 30-minute reference threshold, and the anesthesia-to-incision interval accounted for most of the observed DDI difference between urgency categories. These exploratory findings support risk-stratified, process-based DDI audit but do not establish a causal effect of any individual interval.