Maintaining consistent excellence in the practice of obstetrics is a daunting task. Tempering patient hopes and wishes with timeliness and accuracy of diagnosis are challenges obstetricians face every day. Possessing both the understanding and experience of the subtleties in the management of all stages of labor is expected. We must be able to discuss the option of labor in one woman with a history of one (or more) prior cesarean deliveries while counseling another about the benefits and risks of any labor at all. All the while we must be sure to be available to appropriately respond to clinical emergencies, be they sudden and unexpected or the result of some calculus leading to the conclusion that the fetus is not appropriately tolerating labor and immediate delivery is indicated. We attempt to stay current with the latest standards, maintain our clinical skills, and maximize patient safety while practicing evidence-based medicine. Most importantly, we understand and appreciate that high-quality obstetrical care requires a dedicated team of skilled individuals who respect one another, effectively communicate, and are able to work cohesively at all times.

One of the more challenging clinical standards obstetricians face is that which arises in a setting of deteriorating fetal labor tolerance demonstrated by concerning changes in the fetal heart rate. When emergent delivery is indicated in such a setting, the time from decision to perform a cesarean section to skin incision is expected to not exceed 30 minutes. Although adopted some 25 years ago by the American Congress of Obstetricians and Gynecologists and subsequently by the Royal College of Obstetricians and Gynecologists and the American Academy of Pediatrics, there has been little scientific evidence demonstrating improved measures of clinical outcome that would support this recommendation. While fetal pH and oxygenation have been shown to have an inverse relationship with the duration of time for intrapartum emergencies such as cord prolapse, placental abruption, or uterine rupture, the same physiological changes have not been established, with rare exception, for the far more common cases of intermittently or persistently abnormal fetal heart rate patterns being the indication for emergent cesarean delivery.

However, Weiner et al, in this month’s American Journal of Obstetrics and Gynecology present a study suggesting a decrease in the incidence of various measures of potentially adverse neonatal status following the initiation of an institutional program designed specifically to shorten the decision to delivery interval (DDI). Their study is limited to cases of emergent cesarean sections for “nonreassuring” fetal heart rates. Implementing an intense department-wide approach at their facility, they report a markedly reduced mean DDI in an ensuing 27-month period to 12.3 ± 3.8 minutes compared to the prior 27-month mean DDI of a very respectable 21.7 ± 9.1 minutes. Of note, approximately only half of these women were in active labor. While there was no change in any measure of maternal outcome there was a significant change in certain neonatal parameters including the incidence of umbilical cord pH ≤7.1, 5-minute Apgar score ≤7, and specifically identified composite adverse neonatal outcome. Unfortunately, the authors do not disclose the incidence of cord pH ≤7.0, 5-minute Apgar ≤3, or base deficit of >12 mmol/L, which are more commonly utilized measures of concerning neonatal status. Additionally, it is unclear if there was any change in the rate of cesarean delivery for the specific indication of nonreassuring fetal heart rate between the study groups. The reported findings are all the more interesting when one considers that 82.5% of such births had been accomplished with a DDI of <30 minutes in the initial cohort of cases, which would meet the standard of care and is a performance that likely exceeds that of many hospitals currently providing obstetrical care.

What clinically relevant information should we take from this provocative study? This appears to be the first report suggesting a relationship between various measures of potentially adverse neonatal outcomes and length of time from decision to delivery when the delivery indication is limited to abnormal fetal heart rate. There is an important study concern that needs emphasis and is recognized by its authors. Specifically, while reviewing the various fetal heart rate tracings for both study periods the investigators found similar rates of category 2 and category 3 patterns yet there was no specific requirement or definition of fetal heart rate abnormality that established the need for emergent delivery. This reality is shared by everyone treating a woman with an abnormal fetal heart rate and represents both a challenge and an opportunity for the development and study of specific management algorithms for such clinical situations that include but are not limited to emergency cesarean section. Another concerning aspect of this report was the significant increase in the use of general anesthesia and significant decrease in spinal anesthesia in the shortened DDI group. While there were no reported untoward maternal complications, when compared with conduction anesthesia, although rare, maternal risks are increased with general anesthesia. Further, with study patients having an average body mass index of 24.1, this cohort of women is not representative of the patients cared for by many obstetrical providers. Caution is urged in interpreting the results of this study as necessarily demonstrating improvement in overall neonatal outcome resulting from a further shortening of the DDI and should be tempered by the concerns noted.

For any delivery unit, the fact remains that the 30-minute rule is the current standard. Consistently meeting this standard has many challenges that include availability of the surgeon, surgical suite, and obstetrical anesthesiology services. There are critical patient issues that must be rapidly considered and prioritized such as physical findings and comorbidities, medical and surgical history, informed consent, laboratory assessments, intravenous access, and rapid, safe transport to the operating room. Every member of the obstetrical team and administrators charged with managing hospitals that provide obstetrical services must understand that the only way to achieve this standard is by embracing a focused, refined, and dynamic program of performance improvement. This requires buy-in from all providers, an ongoing assessment of performance with transparency and sharing of clinical data, identification and removal of barriers to improvement, and peer review of potential outliers. Most important, however, is maternal safety. Overlooking the mother as the patient cannot be tolerated and would be a critical error in any effort to achieve this standard or further shorten the decision to incision timeline with the belief that such an approach is necessarily associated with a better outcome.