In response to my editorial “Decision to incision: time to reconsider,” Dr Elliot M. Levine makes several excellent points. One is the difficulty in arriving at a definition of fetal intolerance to labor that providers can agree on while the other is the difficulty in assigning a precise decision time. As to the first point raised, I believe that we can agree that a Category 3 fetal heart rate tracing as well as obvious signs of maternal distress would be conditions that should result in a decision to incision interval that is not longer than 30 minutes. The second issue is more problematic and will need a clear definition that American College of Obstetricians and Gynecologists should provide its membership when it convenes a group to address the overall issue of the decision to incision interval.

It is interesting to note that a recent article entitled “Uterine rupture with attempted vaginal birth after cesarean delivery” reported on 36 cases of uterine rupture with signs of uterine rupture being fetal related in 24 cases and maternal related signs in 8 cases. They report that no neonate delivered in fewer than 18 minutes had an umbilical pH level below 7.0 and the 3 neonates who delivered at more than 30 minutes met criteria for an adverse secondary outcome. Time is truly a critical aspect of those situations when fetal or maternal distress is documented.

I am pleased that Dr Levine supports a modification of the accepted 30-minute rule, and it remains my hope that an American College of Obstetricians and Gynecologists’ committee will address this issue for clarification and direction to its membership.