We appreciate the reader’s insightful comments regarding our report about the effect of a program to shorten the decision-to-delivery interval (DDI) for emergent cesarean section on maternal and neonatal outcome.

Our program was designed to shorten the DDI in cases in which the decision for an emergent cesarean section was based only on nonreassuring fetal heart rate (NRFHR), regardless of any subcategorization. We found that before and also after the implementation of our program, 92% of the emergent cesarean section for NRFHR were performed because of category II tracings and about 8% were based on category III tracings (of 3-tier classification of fetal heart rate patterns). We agree that the urge to deliver as rapidly as possible in every case of NRFHR is problematic. A clear definition for urgency seems mandatory, yet we found that our program was safe and it improved early neonatal outcome.

Inevitably, the more severe rapidly deteriorating cases and irreversible causes for NRFHR, such as cord prolapse, placental abruption, and uterine rupture, probably benefited from shortening the DDI, as described previously by others.

We believe that monitoring DDI in labor wards is of major importance. Identifying obstacles responsible for delay, increasing the availability of anesthesiologists in labor wards, and improving communication between pediatricians and the surgical team remain essential in improving quality in obstetrical units. Efforts to implement programs to shorten DDI should be tailored based on local guidelines, labor ward structure, and staffing.