Letters to the Editor

Elective CD before 39 weeks

The recent flurry of publications and statements by professional organizations regarding the risk of elective cesarean delivery prior to 39 completed weeks of pregnancy continues to confuse the issue of late pre-term delivery with that of early term delivery. The risk of complications of babies born at or less than 37 weeks is well-known and universally accepted, in terms of both relative and absolute risk. However, although the relative risk of neonatal morbidity is increased between 38 and 39 weeks, compared to the risks at 40 weeks of completed gestation, the absolute risk remains very small. I would hope that some reliable analysis could be performed regarding not only the issues raised in Dr. Lockwood's very appropriate editorial ("Elective repeat CD before 39 completed weeks can be risky," March 2009), but also the absolute risk of neonatal morbidity compared to the absolute risk of neonatal and maternal morbidity and mortality of a continuing pregnancy for an additional week. Many authors choose to include data in papers presented on this issue that really relate to pregnancies much earlier in gestation than those affected by the guidelines discussed, and they rarely discuss the potential complications of continuing pregnancy. I am concerned that in an effort to ensure that babies are not delivered electively prior to 38 weeks, we may be failing to fully objectively analyze the alternative issues. I greatly appreciate the thoughts and insightful discussion by Dr. Lockwood.

LARRY P. GRIFFIN, MD
LOUISVILLE, KY

Where is our collective conscience?

"First do no harm"...Those words, I so vividly recall, were repeated by each one of us as we took our oath and entered the noblest of professions: medicine. This is why it so pains me to see how easily they have been forgotten and to see the tragic path we are taking. It seems the motto for our day is to "fix everything up," patch up all insecurities by attempting external perfection, at any cost, and at great financial rewards to those willing to partake in that path.

We claim to be women's physicians and that our primary concern is their mental and physical well-being. Equality and women's rights are what we seek and bettering the future of our mothers and their offspring. Yet at the same time, and in the name of a woman's right to make her own decisions when it comes to her body, we are succumbing to more patient- and media-inflicted pressure, and heading to the point of no return. This is exemplified by the ever rising unacceptable rate of cesarean sections, by the drastic reproductive measures for fetal sex selection, not to mention the most sophisticated new avenue for further objectifying women: plastic surgery. More and more of our patients are on a number of antidepressants and anxiolytic medications and at much younger ages. More of our patients are seeking medical procedures that are not evidence-based, and more dangerous surgical procedures are being performed by unqualified physicians, driven by ample financial rewards.

No red lines exist anymore, and I can't help but wonder about what lies next after the most recent craze of labial reduction. Is this really bettering the status of women-or further victimizing them where they are now seduced into thinking that they are attaining freedom and equality when in reality they are now caged by their own vanity? Instead of resources being directed to perfect the talent and beauty that lies within, which in reality is what radiates to the outside through poise and confidence, today all resources are focused on the outside, and being made known through massive advertising in our medical journals as well as in the most widely circulated women's magazines. This instills further insecurity in those with limited means. And more dangerously, are the complications being brought forward? Are our patients aware of all the surgical and anesthetic risks? Do they know about the deadly, though remote, chances of DVT, wound dehiscence, foot drop, as well as keloid formation in the areas of those labia they were so eager to cut off?

Where are we, the gatekeepers? Where is our collective conscience? What message are we relaying to our daughters as their mothers? And how have we allowed the once "feminine" yet too perfect Barbie, so idealized by all little girls and their brothers, to be replaced by the "Bratz," who so defies all rules of nature, with whom we are now imprinting the young minds of our sons and daughters as to what the true beauty norms are for generations to come? The primary goal for any young teenager is fast becoming achieving that look and at any cost. With this, and in the name of our daughters, I send out a desperate cry for help. I ask each and every one of you to reflect on your own experiences and complications and think of your wives, sisters, and daughters, in every patient encounter. For in the absence of any governing global bodies, and with the media frenzy through the mass ease of communication in this day and age, the only way we can prevent this catastrophe is if each and every one of us acts as a true "gatekeeper." May what brought us into the noblest of professions prevail, and may we repave the path for healthy sane futures for our daughters and their daughters' daughters.

REEM S. ABU-RUSTUM, MD
Tripoli, Lebanon