Welcome to the February 2009 Editor-in-Chief’s page. The articles that have been selected as this month’s “Editor’s Choice” focus on important issues in clinical obstetrics. Rittenberg et al compare 2 strategies for preventing preterm birth. Lal and colleagues address the important  downstream consequence of cesarean delivery: pelvic floor dysfunction.

• Preterm Birth Prevention by 17 Alpha-Hydroxy­pro­gesterone Caproate vs. Daily Nursing Surveillance

  C. Rittenberg, R. B. Newman, N. B. Istwan, D. J. Rhea and G. J. Stanziano
      

  Few clinical problems have proved as unyielding as that of preterm birth (PTB). Over the past decades, many efforts have been made to reduce the PTB rate. Screening strategies have been developed: scoring systems, ultrasound measurements of cervical length, salivary estriol and fetal fibronectin determinations. Therapeutic strategies have largely focused on tocolytic agents. On the whole, these interventions have been unsuccessful in lowering the rate of PTB. This study compares a relatively new approach, the weekly administration of 17 alpha-hydroxyprogesterone (17P) with an older and largely abandoned approach, daily nursing surveillance with home uterine activity monitoring (HUAM). The use of 17P was not superior to HUAM in reducing PTB rates. Some might view these findings as disappointing since HUAM was shown to be ineffective in reducing PTB rates in a number of large randomized trials. 17P did appear to reduce the diagnosis of preterm labor and the use of tocolytic agents. This finding suggests that the use of nursing surveillance with HUAM led to an overdiagnosis and overtreatment of preterm labor, a criticism that has previously been leveled at this approach. However, the jury is still out on the effectiveness of 17P for reduction of PTB, and a number of trials using other progesterone preparations are still in progress.

• Postcesarean Pelvic Floor Dysfunction Contributes to Undisclosed Psychosocial Morbidity

  M. Lal, H. M. Pattison, T. F. Allan and R. Callender
   
  The practice of obstetrics is entering an era of a cesarean delivery pandemic without an obvious endpoint. Part of the rapid rise in cesarean births has been attributed to elective cesarean delivery on maternal request (CDMR). In the United States, this phenomenon led to an expert panel conference in 2006 which examined the risks and benefits attributed to this practice. This panel concluded that many areas, including pelvic floor dysfunction (PFD), lack sufficient rigorous study and therefore precluded the recommendation that cesarean delivery be offered as a prophylactic measure. The present study examines differences in PFD between patients delivered by cesarean section for elective and for emergent indications. It also compares the cesarean delivery group with a group of patients who delivered vaginally. As has been demonstrated previously, there was a difference in PFD between both groups, favoring cesarean delivery. They also showed, as have others, that cesarean delivery does not prevent PFD. The major importance of this study is that it examines psychosocial problems that attend PFD, a significant quality of life issue for affected patients. The association of dysphoric disorders with incontinence and dyspareunia is not novel but shows a direction for more research, involving larger patient groups, in the future.