The fifth edition of Standards for Obstetrics and Gynecology published in 1982 stated that, “An obstetric service that generally cares for high-risk patients should be staffed and equipped to handle emergencies and to be able to begin cesarean delivery within 15 minutes.” However, in 1987, Shiono et al reported that in a survey of 538 hospitals almost all hospitals had the ability to perform an emergency cesarean section within 30 minutes; and therefore the 15-minute rule was changed in 1988 to a 30-minute rule in the sixth edition of the American College of Obstetricians and Gynecologists (ACOG) Standards for Obstetric Services as well in the second edition of the Guidelines for Perinatal Care. Since then, labor and delivery units all across the United States have been held to this 30-minute time interval, referred to as the decision to incision rule, although there are virtually no evidence-based medical studies supporting such a rule. As happened in 1988, it is time for revision once again.

Need for a rapid response to an obstetric emergency is based on valid scientific studies. In 1972, Myers published work in monkeys reporting that with complete cord occlusion blood brain flow ceased within 5-6 minutes and that surviving fetal monkeys resuscitated after 15 minutes of such complete cord occlusion were noted to sustain neurologic damage. There are other studies indicating that the speed from the time of diagnosis to delivery with real signs of fetal hypoxia is essential to the well-being of our patients.

The important questions that have been raised, however, concerning a 30-minute decision to incision time interval have centered around whether this rule is truly beneficial to infants; how is it effecting our ability to provide appropriate care to our patients without complaints from the legal profession and are labor and delivery units in the United States compliant with the 30-minute rule?

With an anoxic situation, 30 minutes is often too long a time interval to delivery as is noted by the work of Myers; and without a real emergent situation, intervals longer than 30 minutes may not be harmful. In fact, studies have revealed worse outcomes in patients with the shortest of time intervals and that longer delivery intervals did not correlate with an adverse neonatal outcome. This, perhaps, indicates that a prolonged interval between the decision and incision in some instances facilitates attainment of more thorough intrauterine resuscitation or that it may indicate a subgroup of patients in which the fetal distress was more severe and acted on with greater speed.

As to the question of compliance, the study by Nageotte and Vander Wal in this edition of the American Journal of Obstetrics and Gynecology confirms that many labor and delivery units do not provide patients a 30-minute decision to incision interval in cases of fetal intolerance to labor and that this noncompliance did not, however, have a negative effect on neonatal outcome.

Nageotte and Vander Wal reported on 68 patients who were delivered for fetal intolerance to labor (IOL) at a level III community hospital with more than 5500 annual deliveries, having a close affiliation with an academic teaching institution, and in which private practice physicians, medical students, residents, fellows, obstetric anesthesiologists, and Maternal Fetal Medicine subspecialists are in the labor and delivery unit at all times. Even with this array of available providers and specialists, the hospital only achieved a decision to incision time interval of 30 minutes or less in 25% of cases.

The authors describe a series of quality improvement initiatives to raise the level of compliance including making physicians and nurses aware of the situation, ongoing education with emphasis on the importance of achieving the standard of 30 minutes or less, addressing certain patient specific issues involved in the preparation of surgery, making a second operating room available, making 2 anesthesiologists available instead of 1, posting monthly results in the physician and nurse lounges, and sending physicians and nurses inividual notification of their results along with suggestions for improvement. In a final phase, the authors instituted a “Code Green” that used an overhead announcement in labor and delivery when a cesarean section for fetal IOL was called. For all their efforts, the authors were able to improve the dismal 25% rate to 90% with a mean time of less than 25 minutes and 100% of cases initiated within 40 minutes.

The authors noted, however, that during their continuous performance improvement process, a subanalysis of all cases of sudden fetal compromise, which included cases of umbilical cord prolapse, abruptio placenta, placenta previa, acute hemorrhage, and uterine rupture, showed that the response was well within the 30-minute decision to incision time interval. The authors state that, “While cases of acute fetal compromise were delivered in a very rapid manner immediately following the identified emergency, the more common cases of fetal IOL as the indication for surgical birth were commonly not delivered within the established time standard.” This would suggest that in this hospital, as is the case in most other facilities, when a true emergency occurs, the team of providers can and do meet the 30-minute standard. The more common cases of fetal IOL that the authors claim are the bulk of cases that fall outside the 30 minutes are cases that perhaps should not be held to this standard, especially because no study has revealed an improvement in outcome when a 30-minute decision to incision time interval had been met as well as unnecessary rushing to surgery may impact negatively on maternal safety.

This study, along with a considerable amount of supporting evidence, strongly suggests that it is time for ACOG to refine its long held standard of a 30-minute decision to incision rule established in 1988. The 30-minute rule was put into place initially to emphasize that a brief time from diagnosis of an obstetric emergency to delivery was critical and labor and delivery units should be able to perform a cesarean section in a very rapid fashion. The 30-minute rule was helpful during several earlier decades to convince hospital administrators as well as providers of pregnant patients that they needed to have the resources and personnel to be able to respond to real obstetric emergencies. That message has been well received throughout this country, and the vast majority of hospitals now are able to comply with a time interval of much less than 30 minutes when the need to do so presents itself.

It is essential that all hospitals offering obstetric services be able to respond to emergencies in a rapid fashion so as to avoid serious maternal, fetal, and neonatal consequences. It would seem reasonable to maintain a 30-minute decision to incision rule; however, the rule should clearly state that it should only be the standard of care in those small percentage of cases that are considered to represent defined obstetric emergencies and/or category 3 electronic fetal heart rate tracings. Anything less should be held to a standard of being performed in a timely manner. This change in emphasis would do much to bring hospitals and doctors throughout this country into compliance with standard of care principles while at the same time not having a negative effect on patient outcome.