Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 10.1: VBAC Updates, Estrogen Packs, Co-Sleeping, and More!
Howard and Antonia dive into their tenth season with a critical look at several new studies. Topics include:
• Estrogen-soaked vaginal packing after surgery lacks evidence for benefits while carrying unnecessary costs
• Recent studies on vaginal birth after cesarean deserve careful interpretation beyond aggregate outcomes
• Hospital uterine rupture rate is 0.2-0.4%, with only 8% resulting in catastrophic outcomes when properly managed
• Warnings against infant co-sleeping date back to ancient times, predating modern pediatric recommendations
• Vaginal hysterectomy continues to decline despite shorter OR times, lower costs, and similar complication rates
• Swedish study shows only 25% of ideal candidates receive vaginal hysterectomies, with projections showing disastrous decline in rates of appropriate surgeries
Stay tuned for our next episode featuring Scott Guthrie discussing neonatal resuscitation and other neonatal concepts important for OB-GYNs to understand.
00:00:00 Season 10 Introduction
00:01:13 No Evidence for Estrogen Packs After Surgery
00:10:35 VBAC Studies: Interpreting Maternal Risks
00:19:12 Catastrophic Uterine Rupture: Hospital vs Home
00:28:53 King Solomon and Infant Co-Sleeping Dangers
00:39:50 Vaginal Hysterectomy: Declining Despite Evidence
00:54:09 Cost and Time Analysis of Hysterectomy Routes
01:06:24 Closing Thoughts on Season 10
Follow us on Instagram @thinkingaboutobgyn.
Welcome to Thinking About OB-GYN. Today's episode features Howard Harrell and Antonia Roberts discussing VBAC, vaginal hysterectomy and more.
Speaker 2:Howard.
Speaker 3:Antonia.
Speaker 2:What are we thinking about on today's episode?
Speaker 3:Well, first of all, it's season 10.
Speaker 2:Wow, so that means we're very well-seasoned veterans of podcasting.
Speaker 3:now right, Maybe or we're just crazy or something, but yeah.
Speaker 2:Well, I think definitely we're crazy because we don't take breaks between seasons, we just go right in, that's a thing.
Speaker 3:Wow, there's too much to talk about. We used to think it would be hard to come up with ideas. Now it's, should we? Do it weekly Overflowing, if we ever had time to do that, but I can't take breaks from talking about my favorite topics. I know, let's get into it. We're going to talk about some new papers about vaginal birth after cesarean, along with a new study about vaginal hysterectomy in Sweden, and we might even talk about King Solomon and infant co-sleeping. But first, what's the thing we do without evidence?
Speaker 2:Okay, how about placing a vaginal pack soaked with estrogen cream at the end of a vaginal surgery?
Speaker 3:Okay, sure, yeah, so this has been a traditional thing in gynecologic surgery. You finish your hysterectomy or usually you know it's a hysterectomy plus an anterior or posterior repair or some other vaginal repairs, and you put a cling or a Curlex or something infused with this estrogen cream on it into the vagina as a packing for a short time afterwards that might be traditionally it was overnight you put the pack in, patient had a catheter in. They went to their room overnight and then in the morning you took the pack out and the catheter out and gave them the bladderlix with like saline or even bupivacaine or lidocaine. And is there a benefit to putting the pack in, any pack in at all and, if so, for how long?
Speaker 2:Yeah. So this is one of those many things that started because it just made sense to someone and you can see why it seems like a really nice touch to add some pressure and maybe some moisture, maybe a little bit of extra pain medication against all these new surgical wounds we just created. And maybe this has been extrapolated out from some other scenarios that are a little bit similar. For example, if someone just had a baby and they have some pretty big vaginal lacerations, you keep stitching, they keep bleeding and then you put a nice tight packing against it and the bleeding actually stops, maybe you think, okay, I just did this completely hemostatic anterior posterior repair. Maybe I'll put a packing here too just to prevent bleeding.
Speaker 2:So I've seen some patients after anterior posterior repair or perineoplasty come back to their follow-ups that seem to have a bit more pain than patients who just only had a hysterectomy.
Speaker 2:So maybe there's some thought that put a packing in upfront to get a head start against any inflammation that might crop up otherwise and try to reduce their pain. So that's just a hypothetical. Usually if I do an anterior posterior repair I'm not putting packing, I'm just prescribing them maybe some estrogen chem to put in by themselves. But I'm sure if you ask other surgeons who do this packing routinely, they'll probably have their own favorite explanations and theories for why it's a good thing. And a lot of patients who have this prolapse surgery do have some form of vaginal atrophy or just weak tissues that probably would benefit from the estrogen cream to make them stronger, less fragile, more elastic and bring more blood supply. So at some point someone decided out there that if estrogen is so great for the vaginal tissues, we should just pack it in there overnight after their surgery to improve their wound healing and just accelerate their recovery.
Speaker 3:Yeah, we do a lot of things that make sense. I was reading something recently about social media and in alternative health, things that are expressed on there, and people tend to like things that have an explanation, a plausible explanation, like you just gave, about why something might work and a theory about my why it might work. They prefer that over empiric data or evidence and that explains a lot in the world. So nice theories about what might happen, but what does the evidence say? And there's just no evidence that putting in a cling or something that's soaked in estrogen immediately after surgery or using estrogen alone for some period of time leading up to surgery or some period of time after surgery is of any value.
Speaker 3:Estrogen is not a miracle that changes everything in just a few hours of exposure or a couple hours or even overnight. It takes weeks to months to remodel these tissues under the influence of estrogen. And as far as tamponading off bleeding, there's really no evidence that bleeding at the top of the vagina. So if say you only did a hysterectomy, that that would benefit from packing, In fact bleeding from the cuff, if anything may be masked with the pack and you may miss significant postoperative bleeding because it's all being pushed into the peritoneal cavity rather than seeing it come out. That's actually the same concern about after a vaginal delivery.
Speaker 3:You mentioned some of those tears and you could tamponade off a tear in the vagina and then meanwhile miss the uterine acne bleeding. That's significant. So that's actually a great argument for not putting packing in general, because it could mask significant postpartum or, in that case, or postoperative bleeding in this case Now bleeding from an anterior or posterior corporeal feed, just like from an obstetric vaginal tear. You could tamponade that with a pack. But this probably should be done on a case-by-case basis, where you're not satisfied with your hemostasis and so occasionally you use a pack for a couple of hours and keep a good eye on it to provide that tamponade, not as a routine thing, and in those cases you may again need to pay a lot of attention to that patient to make sure that she doesn't have occult bleeding that's hiding behind the packing, or an expanding retroperitoneal bleed. If you're doing that, it should be under specific circumstances for a specific patient.
Speaker 2:Yeah, and in this day and age we're not leaving in urinary catheters overnight in these patients, or even admitting them overnight, at least not routinely. So the idea of packing really is going to be limited to the same day discharge timeframe, like one or two hours in the post-op recovery unit. So in either case, the next question is their benefit of soaking it in something else besides estrogen, like maybe just some sterile saline, because unfortunately some hospitals, like mine for example, do not have any estrogen cream stocked as an inpatient medication at all.
Speaker 3:I'm sure it's disappointing to not have it available.
Speaker 3:If you've worked somewhere else that did have it packed, but there's just no scientific evidence that patients benefit from anything other than saline.
Speaker 3:When it comes to soaking the packing and the estrogen cream itself is very expensive. It's cheaper now there are generics, but historically this was $300 or $400 of estrogen cream used one time for a couple of hours of packing, and so that's why hospitals have stopped stocking it in their pharmacies, because it's just frankly a waste of money. Even the idea of soaking the cling or something in bupivacaine for enhanced pain control or hemostasis while again it may make some modicum of sense isn't evidence-based. In fact, there's a study in the December 2024 Journal of Minimally Invasive Gynecology done by a group of urogynecologists for these sorts of gynecologic procedures we're talking about, and they used either a packing soaked with estrogen cream or bupivacaine or saline, and they did leave them in overnight so that they were taking them out the next day, and they found no difference in any outcome that they looked at, including postoperative pain scores or length of stay or need for narcotic pain medication or urinary retention or anything else.
Speaker 2:Well, that's very interesting. So someone would have to argue that any benefits in estrogen packing are going to be more subtle and maybe less immediate than what that study looked at. But we did talk on here before about a trial published in 2023 in JAMA that looked at whether just vaginal estrogen cream alone before and after pelvic organ prolapse surgery, improved success rates, and they found that at 12 months postoperatively, the estrogen cream group was no better off than the placebo group, at least in reducing the risk of recurrent prolapse and in fact, if anything, the trend was more towards prolapse in the estrogen group. So if many weeks of estrogen use before and after surgery don't benefit the healing or the tissue quality in any way, that's positive then there's really just no way that two hours or 12 hours with a packing is going to make any difference.
Speaker 3:Right, and again the cost is better than it used to be. It's not $400 anymore with generic stuff, but it's still going to be frequently $50 to $100 a tube that you're using all at once. And if patients are doing this and their insurance hasn't paid a lot of Medicare, patients won't have coverage for this as an outpatient. So if you're doing it preoperatively or postoperatively, patients are frequently paying $50 to $100 cash to do that out of hospital therapy too, for perhaps no benefit. So the bottom line is we should use vaginal packing only for short term and soaked with saline, and only in those selective cases where you're worried about bleeding from the vaginal walls not necessarily from the cuff and just soak it in saline, leave it in for a couple of hours, make sure the patient doesn't have extensive bleeding and that's it.
Speaker 2:Okay, well, and there are actually a lot of other studies coming out about this. For decades surgeons have been admitting these patients overnight with their follies and vaginal packs, particularly after the pelvic floor repairs pairs. But then these younger fellows, and maybe residents, are doing studies showing that they can do all of the same thing in a shorter timeframe or not at all, and I think that's in part driven by wanting to send these patients home the same day, which in most cases, after an uncomplicated surgery in a fairly healthy patient, it really should be happening. They should be going home that day.
Speaker 3:Yeah, I do all these surgeries and it's rare to keep a patient overnight and it's almost always for their own medical comorbidities. So the vast majority of patients are able to go home same day, even from complex urogynecologic surgeries and without catheters and things like that Voiding trials. A lot of stuff has just gone by the wayside. As an example of that, there was a study in the International Urogyne Journal in July of 2024 that showed that there was no difference in any outcome if you remove the catheter and the vaginal pack three hours after surgery compared to the next day. So they were just trying to get. They were used to packing them overnight and catheter overnight, and then they said what if we just do it for three hours? That was their next incremental step away from what traditionally was done and they found zero difference.
Speaker 3:And there have been again just a ton of studies showing that patients can take out the catheter themselves if they need to when they go home. If they can't void, send them home with the catheter, they can take it out themselves the next day. They can take it out themselves the next day. I'll also put a link to a 2023 systematic review in that same journal that found that there was no benefit to packing after vaginal hysterectomy and the author has actually recommended against the procedure. So I think that's where the evidence is.
Speaker 2:All right, well, let's move on. I'm sure you saw this new study in the Gray Journal that looked at severe maternal and perinatal neonatal morbidity associated with planned mode of delivery following a prior C-section. So basically, scheduled repeat versus TOLAC. This was a population-based cohort study that included patients from 2003 all the way up to 2021 in Canada, and so it had just over 12,000 women with prior cesareans in Nova Scotia. They reported that for the planned TOLACs there was increasing severe maternal and perinatal morbidity over that time period compared to the ones who did a planned repeat C-section, and they suggested the author suggested that this increase in morbidity was related to the increasing use of oxytocin for induction or augmentation of labor.
Speaker 3:Yeah, it's interesting and a paper worth looking at, but unfortunately, I think the effect of this, of course, will be to argue that women shouldn't be allowed to have a trial of labor after, will be to argue that women shouldn't be allowed to have a trial of labor after cesarean and certainly that they shouldn't have oxytocin augmentation. What they've seen is a significant rise in attempts at a trial of labor after cesarean, as opposed to just planned repeat cesarean deliveries. Along with that have come more successful and also unsuccessful attempts at vaginal birth after cesarean delivery. And the key to understanding papers like this one is a couple of things. Keep in mind it's retrospective, so there's plenty of issues with that, because they're peering back in time and collecting data from different types of data collection systems, which may have aggregated and collected information in different ways and less reliable ways, have aggregated and collected information in different ways and less reliable ways. But the first thing is that this study uses aggregate outcomes, which is a common thing. That can be very misleading when you look into what composes the aggregate outcome.
Speaker 2:Yeah, the aggregate outcome can span quite a wide range of things. For maternal morbidity it'll have things like third and fourth degree perineal lacerations, hemorrhage requiring blood transfusion, but then also strokes and pulmonary embolism and death. So things that maybe are not on this actual same level of severity are all grouped into this same category. And it's the same with the perinatal neonatal morbidity composite. So that'll have things like needing some temporary supplemental oxygen and then also permanent brain injury, which are obviously not on the same level, but they're in the same category here.
Speaker 3:Right and you could debate what the definition of severe is. If you're combining, making an aggregate outcome, what is severe? Do you think oxygen for a couple of hours is severe? Certainly neonatal asphyxia is severe. Or do you think a third degree laceration is severe compared to pulmonary embolism and death?
Speaker 3:So it's hard to imagine that needing to get one unit of blood after having a baby is put into the same category as maternal death. Or, as I said, for newborns, that being on CPAP for an hour is the same as having multisystem organ failure. And we're going to call all that, lump it together and call it severe. And so aggregate outcomes are misleading because most people, when they read a paper like this or the abstract, will assume the very worst about VBAC when they don't dive into it. So we need to disaggregate these outcomes really to see what's changed and what they're seeing.
Speaker 3:And, as you might have guessed, most of the increased morbidity for the mothers in this study was hemorrhaging requiring a butt transfusion, and most of the increased morbidity for newborns was assistive ventilation, not the things that I would have called a severe morbidity for newborns was assistive ventilation, not the things that I would have called a severe morbidity.
Speaker 3:I'll also say one thing when you get into the literature about VBAC and versus repeat C-section, one thing that I think people need to appreciate is it is always safer for the newborns on whole to be born by C-section.
Speaker 3:So some of the same force that might argue against VBAC here.
Speaker 3:If you just want to show that babies have some more problems when they're born vaginally than by C-section, you can do that.
Speaker 3:You can take a group of first-time moms and have 500 of them do scheduled cesareans and 500 of them have attempted a vaginal delivery, with some being successful and some going on to emergency cesarean, and you will always see more of these types of morbidities in the vaginal birth group. So you know more clavicular fractures and shoulder dystocias and more NICU admissions and low APGARs and things like that and, for the mothers too, more third and fourth degree and second and first degree lacerations and all those things. The reason why we just don't section everybody is because C-sections also kill mothers when you scale out to a large enough number to see that, and so C-section is between three and seven times more fatal for the mother and these rare outcomes favor for the dyad as a whole, the maternal neonatal dyad, favors vaginal birth, and so that's why it's really important to think about what these aggregating things are. Otherwise, you're going to quickly be arguing that no one should have a vaginal delivery under any circumstances if you just focus too myopically on some of these things.
Speaker 2:Yeah, I did have a pediatric attending one time. I think half jokingly say like I think every baby should just be born by plant C-section at 36 weeks and just said, yes, sir, we'll let you just keep taking care of the babies.
Speaker 3:But you could make that argument if you drill down on this too far and don't realize that to do so would be to subject an additional what? 3 million women a year in the United States to cesarean, and so you would just see I won't do the math in my head but another thousand or 2000 or so maternal deaths that we don't have. And so it's a balance, and you have to weigh risks and benefits to each of the two members of this diet.
Speaker 2:Yeah, and even what they were saying in this study, like transfusion, assisted ventilation, they're not insignificant. But it's possible that part of this increased rate is really just an increased rate of detection, not a true increased incidence, because there has been a greater emphasis on postpartum hemorrhage over the last decade or so. It's been getting identified and treated better. I remember even during my training we moved from estimated to quantitative blood loss, so that hasn't been too long ago, and just having really tight protocols for managing postpartum hemorrhage, drills and all of that. So that's one limitation of looking at a retrospective trial over such a broad time span where practices change and diagnostic criteria change over then. And in the same way there's probably been a changing emphasis too on the neonatal resuscitation guidelines, so it might look like higher rates of them needing assisted ventilation.
Speaker 2:But really only a prospective trial would tell us how different those outcomes truly are. And obviously if you have more women attempting VBAC, you're going to have our guidelines say, about 1% more uterine ruptures and about maybe, let's say, 20 to 30% of those planned VBACs are going to end up having an unscheduled cesarean in labor because it failed for whatever reason, and so those two things alone might have accounted for everything they found in this study. But if everyone, like you, were just saying, if everyone instead got a scheduled repeat, nobody ever got a chance to VBAC, then of course the rates of intrapartum C-section or uterine rupture will be super low. But then you have nobody that gets a chance at having an easier recovery without an abdominal incision. The overall rate of placenta accreta is going to be higher if everyone gets repeats and then the actual rate of more significant maternal morbidities at least will increase. So I think the only argument left, like you said, is maybe that slight decrease in neonatal risks, but certainly at the cost of a much higher rate of maternal risks.
Speaker 3:Yeah, and that's a good point too, because you're investing in the future, when you have a successful trial of labor. So if you're comparing the second attempt at a trial of labor after cesarean, or the third or the fourth compared to the third, fourth or fifth cesareans, then those differences grow. The vaginals become safer and the cesareans become more and more dangerous. And you don't capture that in data like this either. You don't capture the person whose next pregnancy was a placenta procreta. That was avoided because she didn't have a C-section and in that pregnancy she went into DIC and died. So that's a problem with this. You have to look at those overall outcomes.
Speaker 3:What they actually found was that among the planned vaginal deliveries, they saw that the uterine rupture rate rose from 1.87 per thousand deliveries, which is a really low number, right, that's 0.187% in their early time period to 4.19 per thousand deliveries in the later time period. So that's the more normal number that we think of, somewhere closer to a half a percent. So it seems like the first number was too low, but that later number is the rate of uterine rupture we expect for women attempting a trial of labor. So if anything, again, the earlier number somehow reflects poor documentation, or maybe they weren't really sold on VBAC and people had a trial attempt of it, but the doctors weren't really allowing it. They didn't get a fair go and they got sectioned pretty early when they showed up and they called it a trial of labor, but it wasn't. There's a lot of things in there, but it looks like their higher rate was they just got back to the normal rate.
Speaker 2:Yeah, the ACOG practice bulletins really say something higher, like closer to 1%. So four per thousand is really good actually. And sometimes you will see studies on different things where the comparator, like the historical rate, is unexpectedly low for a certain outcome of concern and that skews the whole interpretation of the study, when really the problem is that historical rate was just poorly recorded or maybe just a weird outlier possibly. But 1.8 per thousand deliveries as a uterine rupture rate is unrealistically low. It just says either they weren't even getting to labor at all or it just wasn't being reported.
Speaker 3:So I'll say the other thing that's clear in their data and we know this is true is that cesarean delivery is safer today than it was 20 years ago, and of course we know that's true.
Speaker 3:The authors acknowledge that they had insufficient numbers to say anything about the more rare outcomes that most people are actually really worried about when you have this discussion. They do acknowledge the possibility that the diagnosis and the recording of these diagnoses have improved over time. I have no doubt about that too, as we've, like you said, been more diligent and had electronic reporting systems and things like that. So their best argument against this what we would call an ascertainment bias is that the rate of uterine rupture is a thing that, like it happened or it didn't happen, right, that's a pretty big. It's not like we forgot to write down that the baby had some supplemental oxygen. If the uterus ruptures, that seems like a thing you would really find out about. But again, they had this remarkably low rate for some reason that is inexplicable, at the beginning of their study period. So again, the rate of interruption in the latter part of the study is what we understand the rate of interruption to be.
Speaker 2:Yeah, so this is just yet another example of how we have to be detectives and read between the lines of any study that we're interpreting. I think a troubling thing about this study is how they aggregate outcomes, like we just talked about, to make the reader assume the worst and assume it's all death moms dying, babies dying because of VBACs. It doesn't give any context about the subsequent pregnancies, and a big part of going for a TOLAC is to make those subsequent pregnancies safer. And we have to remember that we're comparing the safest type of cesarean, which is a scheduled one, to the most risky type of vaginal delivery, which is the first vaginal birth after a prior cesarean. But for many women, like you said, we're investing in the future of their family. If they want to have a bigger family, they want to reduce their risk of percreta and more complicated cesareans, then going for a TOLAC is really the way to go.
Speaker 3:And, like I said, it's always safer for a baby to be born by a cesarean than it is by a vaginal, and that's just always true, even if it's by a slim margin.
Speaker 3:So it's just unfair to link all these aggregate neonatal outcomes together and obviously an aggregate neonatal outcome of babies born by vaginal are going to be higher than babies born by elective cesarean. That's just always true. So it would also be wrong to argue that we should just have cesareans for every pregnancy because of that. Because, like I said, eventually you're going to see the dead mothers, you want the mother to be well enough to take care of the baby, to bond with the baby, and you're putting her at triple risk of severe complications, not to mention the pain of the incision, the wound, infections, and all that in some cases just for very minor benefits like decreased oxygen consumption in the first couple of hours or things like that.
Speaker 3:So this study wasn't large enough, as they acknowledged, to see the real adverse effects that you're worried about, like maternal death or things like that that are associated with elective, repeat cesarean, particularly high order cesareans that's. Another thing about this is that these patients, by definition, were all VBAC candidates, so you're not seeing the patients in here who are having their third or fourth cesareans with the accretas and things like that, who previously elected not to VBAC, you're just seeing the healthiest sort of women having repeat cesareans, meaning that they're having their first repeat cesarean, not their third or fourth. And if you included those patients, that's where you start to see the negative cesarean morbidities.
Speaker 2:Yeah, that's a good point. And we can't escape the fact that of course, if women are attempting a vaginal delivery ever, then there's going to be more risk of a third or fourth degree laceration and uterine rupture and shoulder dystocia and brachial plexus injuries. But why are they taking these risks? It's because they want to hold their babies immediately after birth, not be strapped down to an OR table. They want to be able to start maybe breastfeeding, maybe go home day one. That's how you get women who have zero incisions to heal from or zero narcotic requirement, zero bandages on their belly all of that good stuff.
Speaker 2:When people want a trial of labor because they've already been through a cesarean, that's what they're gambling for. And of course you can look at individual risk factors and try to estimate what's the chance that it'll work for you if you try to labor. But if someone's considering this and they already have experienced a cesarean they know what that's like and let's say they have maybe a 70 plus percent chance of having a vaginal birth and not having to go through everything that went with the cesarean, then maybe some women want to take that chance. Maybe some women will opt to stick with what they know and say just give me the C-section. Either option is completely fine once they've been adequately educated and informed on the risks and really truly offered either one. But all of those things. They're always true when you compare any type of vaginal delivery to any type of C-section.
Speaker 3:Yeah. So I think the bottom line is the study doesn't really add anything to what we already know, but expect this to be used as cannon fodder for people who don't want to do trials of labor after cesarean. This will be their evidence-based reason quote unquote about why they don't do trials of labor or why they don't offer oxytocin augmentation or things like that.
Speaker 2:Well. On a similar note, in the May 2025 Green Journal there's an article about uterine rupture trends in patients pursuing trial of labor after cesarean in the US from 2010 to 2022. And this had a similar study methodology to the Canada study we just talked about, but it looked at over a million deliveries and this included almost 3,000 uterine ruptures, and over the time period the rate increased from 0.2 to 0.37% and this might also reflect maybe a broader population of patients that are attempting VBAC maybe more oxytocin augmentation, maybe more inductions, but the authors of this paper still say that this is an incredibly low rate and it's lower than what we often think or quote to patients.
Speaker 3:Yeah, meaning that it's not bad that the rate's gone up a little bit because it doesn't change the fundamental risk calculation as long as it's under half a percent or so. And it probably is the case both in this US cohort and that Nova Scotia cohort, that women are attempting trials of labor who weren't the best candidates. If you go back 15 years ago, maybe I really want you to show up in spontaneous labor and I was going to try to talk everybody out of it. Like what was your had a breach the first time, not any arrest disorder or labor abnormality. So you probably do have a group of women who might not have been considered as good of a candidate.
Speaker 3:But I think that this is a better paper and it's certainly got more data to draw on and that that's probably a fair assessment. I also think that we have to keep in mind that uterine rupture rates alone are not the important issue. It's catastrophic uterine rupture rates that are important. So it's possible that an increased risk of uterine rupture rates that are important. So it's possible that an increased risk of uterine rupture is associated with no change or even a lower risk of catastrophic uterine rupture.
Speaker 2:I think you're going to have to explain that one a little bit.
Speaker 3:Well, so a lot of women who are allowed to have a vaginal birth after cesarean in a hospital, or even, in some cases, an induction of labor for vaginal birth after cesarean in the hospital. These are the patients who, if they had not been allowed to do that, might have chosen to have a trial of labor at home if the doctor or the system put up too many barriers to that happening in the hospital. So if we had some big lever where we could push down the rates of women who are undergoing a trial of labor in the hospital because all the doctors are refusing to do it or hospitals are putting up roadblocks and policies. Well, in the hospital, the rate of catastrophic uterine rupture meaning where the newborn usually is permanently injured or killed is only 8% of the ruptures that happen. So out of 100 ruptures that happen in a hospital setting 92 times out of 100, the baby's still going to be, okay, that's what we do.
Speaker 3:But then patients, when they're not allowed to attempt it in the hospital, then they try to have it at home, and this is increasing as hospitals and doctors put up more roadblocks and I see quite a few patients who are considering or have attempted or will attempt a trial of labor at home because their local hospitals aren't allowing them the option of a VBAC.
Speaker 3:Now, at home, the catastrophic uterine rupture rate is 100% of all uterine ruptures. You don't have a uterine rupture at home and have a living or neurologically intact newborn. So part of what we do is we make the process of a trial of labor after cesarean as safe as possible, and a doctor who thinks that he or she can preclude women from doing it just because they told them not to is foolish. So when you look at this from a systems-based perspective, being more permissive of uterine rupture and having a few more uterine ruptures occur in a hospital setting rather than in an outpatient setting or women attempting to even, just even they plan on coming to the hospital, but they want to show up in active labor. They want to really be seven centimeters when they get there that's what their doulas told them so that they can be less likely to get a section. They're going to have uterine ruptures at home. So by being more tolerant and permissive of trials of labor, we're actually saving lives, potentially at least.
Speaker 2:So what you're saying is all uterine ruptures without intervention will become catastrophic, whereas with immediate intervention in the hospital there's still a very high chance of a good outcome. And so that is still about 8% of ruptures even with intervention, and not just the home births?
Speaker 3:I guess yeah, 8% of uterine ruptures that happen in a hospital unfortunately still end up with a catastrophic outcome, despite our best efforts.
Speaker 2:Okay, yeah. So bad outcome for baby, or even for mom too, potentially, yeah, yeah. So 8% of 0.37% so that was what we just pulled from that one study is much better than 100% of 0.37%, so we could probably say that more plainly. So, out of 10,000 women with prior cesareans who have a trial of labor in the hospital, you'd expect 37 uterine ruptures, of which three would end badly. But out of 10,000 women who try to be back outside of the hospital which hopefully it wouldn't be that many, but just for comparison then all 37 of those ruptures would have a really terrible outcome. So our job ultimately is to tell people the most accurate data that we can and help make some joint decisions with them, and I think these numbers can help a great deal with counseling about this.
Speaker 3:Yeah, the way you put that. Those numbers are good. So imagine if you could lower the uterine rupture rate back down to 0.2% because you withheld oxytocin and you didn't do augmentation and you didn't induce anybody and you just took that off the table as a policy, which hospitals do, right. They make a policy that we won't use oxytocin, or individual doctors make a policy, de facto, that they won't use oxytocin, so you go back to that lower rupture rate at 0.2, then you would still have 20 ruptures per 10,000 trials of labor, and two of those, roughly, would be catastrophic injuries. So you'd save a catastrophic injury per 10,000 trials of labor.
Speaker 3:The problem, though, is by having that policy, you may significantly increase the proportion of women seeking a trial of labor outside of the hospital setting, and so the number needed to harm is only 270 with the numbers we just laid out, so as low as 1 in 500, if you use the lowest uterine rupture rate. Depends on which uterine rupture rate you use. But what that means is that if, out of 10,000 women, if you deny them 10,000 trials of labor, if you deny them all oxytocin because you think it's bad, and even 350 patients the average of those two numbers decide to do it at home because the hospital is not being permissive, then you have done now more harm than good, because one of those women will have a catastrophic injury, and that's really the point.
Speaker 2:Yeah, 350, 500 patients. We easily see that number of prenatal patients with prior cesareans many times over in our careers and in general. We deal with human behavior that sometimes we may view as irrational, but that's why we need to carefully construct studies to understand the impact of different interventions and different attitudes in our practice of medicine.
Speaker 3:Right, and we're living in a day and age where, more than ever, patients are fleeing from the hospital setting and doing it at home because of what they view as a lack of cooperation from the physician. So we definitely are part of that complex system and we have to be careful with it. So, okay, that same edition of the Green Journal we just talked about that has the article, has this really wonderful review on the management outcomes of monochorionic twin pregnancies. It's a really good read, particularly if you take care of these. I typically have one or two monochorionic twin pregnancies at any given time, so I enjoyed reading that. And there's a discussion of the Solomon technique in that article and I'd heard that name before but had forgotten it. So I know I'd read about that name for that before, but when I read it it seemed new to me.
Speaker 2:Right. So that's the fetoscopic laser ablation procedure that's used to treat the twin transfusion syndrome. They coagulate the entire vascular that they call equator of the placenta, like the midline between the two twins' cord insertions, to eliminate any residual anastomosis, and functionally it creates a dichorionic placenta by separating out the vascular territories of each twin.
Speaker 3:Yeah, and I talk to patients, I counsel them about this, but I didn't remember it being called the Solomon technique, and so now I'm going to embarrass myself and admit that I, when I read that again, I thought oh, this is an eponym. And then I wondered is this a female eponym, Especially since it's a more recent? This has come about in the last 15 years or so. It would be a more modern eponym and we're always looking for new female eponyms.
Speaker 2:So I went to look it up. Yeah, I don't remember learning about it as the Solomon technique either, but I did learn about this technique even in med school. But technically it is an eponym, but it's a very ancient, gruesome one. You and Maddie had just talked about the Jane point for laparoscopic surgery, for trocar entry, in the last episode, and that was a female eponym that we hadn't talked about before. And, of course, for our listeners who don't know, we're always on the lookout for some good female eponyms. So if anyone has some more out there, let us know.
Speaker 3:Look out for some good female eponyms. So if anyone has some more out there, let us know. Well, this, of course, is named after King Solomon. The Solomon Technique is a biblical reference to the judgment of Solomon in the Old Testament, and somehow that just didn't occur to me in reading that or in times that I've read about it before.
Speaker 2:So are you saying, you're just not that?
Speaker 3:clever. I guess that's one interpretation. Okay, it went over my head. Okay, the pun went over my head.
Speaker 2:Fair enough, it happens. Well, as a quick refresher for people that are not too familiar with Old Testament stories, in this one there's two women who lived in the same house. They each had a son. Two women who lived in the same house, they each had a son, and one woman's child died, probably of SIDS, presumably, or some illness. She got up and stole the other woman's child in the night and switched her dead baby for this other woman's living baby. So the other woman wakes up to breastfeed her baby and discovers it's dead, but then she looks and says this isn't my baby. So the other woman wakes up to breastfeed her baby and discovers it's dead, but then she looks and says this isn't my baby.
Speaker 2:And so then they end up in court in front of King Solomon, and his decision is go get a sword so he can cut this living baby in half and give each mother one half of this living baby, since they can't agree on who it actually belongs to.
Speaker 2:And then the woman who is the real mother of the living baby begs Solomon, don't cut this baby, let him live, let him stay with that other lady if we need to, because she cannot bear to see her own child actually be killed, whereas the I call her the thieving woman it she's apparently all for this. She says, yep, cut him, I'll take one half, give her the other. She already lost her real baby and maybe she wants to see things evened out. So that's how king solomon knows which woman is the real mother, the one that expressed compassion for the child and said don't kill him. And so then he gives the baby back to that woman, takes him away from the one that stole him, and I don't think they go. They don't go much further into it, but I bet the real mom probably wanted to move out or get as far away as she could from this kidnapping mom. They don't give us that information.
Speaker 3:You would hope one would assume yeah, yeah, yeah. So the idea with the Solomon technique is that you split the placenta at least completely in half so that both babies can live. So it's not entirely parallel to the biblical story in any way. But in the case of monochorionic diamniotic twins that are affected by twintwin transfusion syndrome, you can either do selective or, in this case, complete fetoscopic coagulation of the vascular equator of the placental disc, and they use a laser to photocoagulate some or all of the vessels. And the Solomon technique is then the complete separation complete method, and there's been a lot of studies recently comparing this to the selective, the complete method. The Solomon technique is more effective at preventing twin-to-twin transfusion syndrome but may have other consequences.
Speaker 2:Yeah, apparently there's a lot of evolving thought about which technique may be preferred and a lot of small single-institution type studies so far, and some institutions are probably better at it than others or maybe select different types of patients than others. So it's definitely still the gray area and there aren't really fantastic studies on it just yet.
Speaker 3:Yeah, this is one of those things that if you have to send a patient somewhere for it, you're probably better off with what that institution's good and what the individual operators are experienced with.
Speaker 3:So, but I want to go back to the biblical story about King Solomon, because there's a lot of interesting issues in there. So, as you mentioned, there's this possibility that the first infant son died of SIDS. So the text in 1 Kings 3 says that the child died because the mother laid on it, implying a smothering type death. I think that's interesting because it shows, first of all, that the dangers of co-sleeping have been known for millennia and also that what we might call SIDS is really nothing new. It's not due to vaccines. And then I think there's also this issue of how the mother dealt with the grief of the situation. So this was a newborn and I can imagine she might have lacked awareness as part of her grief reaction and perhaps associated with postpartum depression or even postpartum psychosis. I can imagine that she switched the children and was in denial about it, that she may have legitimately believed that the child was hers as part of this psychotic grief reaction, and that her pleas to King Solomon might have even been legitimate and not feigned.
Speaker 2:You were acting like you didn't know who Solomon was. But clearly you've really thought about this. But so the whole point of that story, I think, was just to show how wise King Solomon was and how he could see into human behavior. But I guess, if just to go off what you're saying, if you're saying he could recognize nuances of postpartum depression and psychosis, and that this wasn't just some kind of mean spirited jealousy on the woman who lost her baby, then I would have hoped they could have added in something about how this wise King Solomon also would have ordered her to get help somehow, like maybe some I don't know antidepressant herbs or go see the priest or some kind of counseling, whatever it might have been.
Speaker 3:I'm talking to a tough crowd here. I'm not saying that they had all this figured out, but I do think that we can read between the lines and today we might have diagnosed this patient with a grief reaction and psychotic reaction.
Speaker 2:Well, it is an interesting take though. I appreciate that. But you are right about how far back SIDS goes. The Brits would call it cot death and it's been known about since ancient civilization and it was frequent enough of a problem that we do see lots of ancient writings about it. In Mesopotamia they believed there was a goddess named Lamashtu who would come at night and just kill infants. And of course in the Old Testament, as you just read, they were looking for a more natural explanation, like the baby was smothered, and it's probably difficult to tell in more ancient times the difference between infanticide versus accidental or natural death. And when you mentioned postpartum psychosis, I thought maybe you were going to say like maybe the mother on purpose had a psychotic break and killed her newborn and then, in that same psychosis, just switched the babies.
Speaker 3:That's certainly possible.
Speaker 2:We're getting into dark stuff here. The Roman physician Soranus thought that mothers could become intoxicated and either just not take care of their babies or perhaps accidentally roll over onto them in a drunken stupor, causing them to die, and he actually specifically warned against co-sleeping. I have a quote from him. Besides, the newborn should not sleep with her, especially in the beginning, lest, unaware, she roll over and causes it to be bruised or suffocated. For this reason, the cradle should stand either alongside the bed or, if she wants to have the newborn still near the crib, should be placed upon the bed.
Speaker 3:Wow, so the recommendation actually hasn't changed much in 2000 years.
Speaker 2:Yeah, I guess not. I think they don't recommend having the crib sitting on the bed, but I bet people still do that. Infant co-sleeping is one of those things that patients routinely do and will routinely ignore the recommendations of the pediatricians or the OBGYNs, and there's a lot of social media posts out there that argue in favor of co-sleeping.
Speaker 3:Yeah, well, that brings us to an idea that we have for season 10, where we can do a segment on these episodes where we discuss some social media influencers and some of the claims at least, not the influencers, but some of the claims that we see and one very popular Instagram account that advocates for co-sleeping makes wild claims about the potential benefits, including that your child will have less psychological problems, will have less problems with separation, anxiety, be smarter, do better academic performance, be more independent, healthier all sorts of perceived benefits while at the same time claiming that doctors essentially know nothing about newborns or infant sleep or mothers, and that no baby has ever died a result of co-sleeping and that there are no negatives and no downsides to it at all. And this account, of course, has millions and millions of followers.
Speaker 2:Obviously that's very much an extremist and false view. And if we're just going by the truth of a social media account, then unfortunately there's numerous accounts mothers out there have made chronicling their own baby's deaths due to SIDS, and a lot of times there is something like co-sleeping or maybe having those really padded baby loungers involved. Not always, of course. There are cases where everything was done by the book and something still happened to the baby, cases where everything was done by the book and something still happened to the baby. And obviously these accounts are very distressing to scroll through, although I have to say, in the face of such bad misinformation, maybe it's not a bad outlet for their grief because it does bring some awareness against those extremist pro-co-sleeper influencers.
Speaker 2:And I think there is also a middle ground where a person could make the argument that the risk is small if they've taken some appropriate precautions and their child is old enough, like, let's say, you have a three-year-old who gets out of his bed and runs up to your bed in the middle of the night to snuggle in.
Speaker 2:At that point maybe the risk that your three-year-old will die from smothering is reasonably small. I don't think that there's any stance that AAP has against that specifically. I've never heard of it of that age, of a kid being smothered, but I have heard of plenty like three months, six months, unfortunately, just their parents wake up and the baby is dead. So it's a totally absurd thing to say that co-sleeping, especially with a newborn or an infant less than one years old, is without risk, or that it makes them smarter or anything like that. So, this particular influencer, you're bringing up claims falsely that there's no science or evidence about any risks of co-sleeping, while on the other hand, making these completely wild, unproven claims about its benefits where there's no evidence for that either.
Speaker 3:Yeah, and worse, when there are what we would call SIDS deaths or infant deaths, many of these influencers have to create out of whole cloth other reasons why the infants might have died.
Speaker 3:And that's why I made the little jest earlier about vaccines, for example, because they will claim that some do claim, for example, that vaccines or other things are the cause and that this never happened before, which was the neat part about your tour of history.
Speaker 3:This did happen, so much so that the most esteemed Roman physician recommended routinely against co-sleeping because common sense told him what was happening or he didn't understand it completely. We have a much more nuanced understanding, a three-hit hypothesis, about what happens in a SIDS death today than we used to, a three-hit hypothesis about what happens in a SIDS death today than we used to. But OK, well, we're probably not going to list specific accounts when we talk about them, because we're not trying to call people out or give them publicity. We may talk about some good accounts and some people doing some good work this season, and we'll highlight those folks. And of course, the truth is it's not one or two accounts that make these sorts of claims, but there are just thousands of reels out there, small influencers and big, who make many of the claims we're going to talk about this season Now.
Speaker 3:Each year in the United States 3,500 infants die of sleep-related infant deaths and that includes SIDS deaths but it also includes just frank suffocations and strangulations and sheets and things like that. The number of deaths actually declined pretty steeply in the 1990s as public health campaigns encouraged back sleeping and other safe infant sleep practices. But then it plateaued, at least partially, because there was a backlash of misinformation about safe infant sleep practices. But I'll put a link to the American Academy of Pediatrics document about this which is really good and goes into detail about their sort of three-hit hypothesis.
Speaker 2:I'll admit my strategy has been to just block social media completely, so I'm a little bit more out of the loop about it. But, as I mentioned, there's all these really distressing things that the algorithm will feed you, like seeing the misinformation and then seeing the downside of it, and just over time it was showing me tons of accounts of my baby died and then on the flip side here's why you should still keep co-sleeping with your baby, and so, anyway, my strategy was to just stop getting on there and I highly recommend that for anyone who maybe feels like it could improve their mental health too. But I think most people get on social media for a little mental break and like-scientific view of the world and selling distrust and fear of legitimate science. So I definitely I have a few good ones in mind that I hope sometime in the future we can just give them some kudos for combating this. But they're rare among the whole sea of mostly garbage.
Speaker 2:But consumers do have a right to do what they want. They can do whatever they want, but they need to be informed of what the true risks and benefits are of whatever they're going to do and if they're just consuming these social media accounts that consistently lie about benefits and risks that consumers are not informed to make an appropriate decision. We can also link to another AAP position statement with scientific evidence about their sleeping recommendations, and I'll just summarize they recommend supine, sleeping on the baby's back on a firm flat surface. And they suggest you can share a same room, but don't share a bed and avoid any soft bedding and also avoid overheating, so you probably don't need to overly bundle them up or have like a heated mattress pad, unless you live in the really extreme cold weather, I guess. And then, going along with this, to reduce the risk of SIDS, they recommend breastfeeding if possible, avoiding exposure to nicotine and alcohol and opioids, marijuana, other illicit drugs. They do recommend, of course, routine immunization and they also recommend offering a pacifier.
Speaker 3:Okay. Well, I can't wait for some influencer to suggest that mothers should take up smoking and using illicit drugs simply because the medical establishment has recommended against those things.
Speaker 2:I hope they wouldn't be so petty, but I'm sure someone has already done that.
Speaker 3:Okay, well, we had one more article that I need to talk about.
Speaker 2:I remember you and Maddie, which was an amazing episode. Last time you guys were going to talk about a vaginal hysterectomy study from Sweden.
Speaker 3:Well, we were going to talk about it. Yeah, we ran out of time. But yeah, there's an article from March of 2025 called why Not Vaginal? Nationwide Trends and Surgical Outcomes in Low-Risk Hysterectomies.
Speaker 2:I can see why it caught your eye.
Speaker 3:Why not Vaginal? I love the title. I can see why it caught your eye. Why not Vaginal? I love the title. So they comment that of course the rate of vaginal hysterectomies is declining globally and they looked at a 10-year snapshot of their own Swedish registry. They divided patients into a low-risk group and a standard group. Where the low-risk group that they thought these were cases where no one would object to the patient's candidacy for vaginal hysterectomy, cases where no one would object to the patient's candidacy for vaginal hysterectomy.
Speaker 3:So these were women with no prior cesareans, no previous abdominal surgeries, non-obese, and all of them had at least one vaginal delivery before. Then they looked at outcomes and cost by different routes of hysterectomy and even in the standard group these are still patients who had uteruses smaller than 300 grams and no endometriosis. So they excluded all of those patients and they excluded prolapse surgeries from the group as well, with the idea there being that those would be. They would have other repairs and in some cases can be more complicated. So these are really just straightforward women who've given birth before non-obese small uteruses no endo. Women who've given birth before non-obese small uteruses no endo.
Speaker 2:So their low-risk group sounds like the very most ideal candidates for vaginal hysterectomy.
Speaker 3:Perfect Dream candidates, like it should be 100% rate for them.
Speaker 2:Basically.
Speaker 3:Yeah, and somebody you can be forgiven for thinking that a prolapse case would be easier. Honestly, prolapse cases are the harder ones in many cases. That doesn't make a lot of sense to people who don't maybe do this all the time. But yes, these are the dream candidates for nice, simple vaginal hysterectomies, and I hardly ever get one like this non-obese, no C-sections. It seems like everybody's had three or four cesareans, or they have a big fibroid or they're morbidly obese or something. But I like this methodology because they're basically saying here's a group of people for whom there's no real excuse to not do a vaginal hysterectomy.
Speaker 2:Okay, well, what did they find?
Speaker 3:Well. So in that low risk group only 25% of the hysterectomies were done vaginally, and that actually compares to 15% in their standard group. So it certainly doesn't seem like folks are choosing the route of hysterectomy based upon the risks or the qualifications of the patient. I think we already knew that, though they also, of course, found that the rate of hysterectomy declined over the 10-year period and towards the end of that study period one in six of the vaginal hysterectomies were actually V-notes hysterectomies. So I think that's interesting too, because if you think that V-notes might be a way to bring back some laparoscopic hysterectomists back into the fold and make them vaginal hysterectomies I would say vaginal in quotes, because I think it's arguable whether or not V-notes gives the same benefits as vaginal hysterectomy due to the positioning of the uterus, and they have certainly hasn't been proven yet. But I don't think that's what's happening. I think what we're seeing is we're just cannibalizing vaginal hysterectomies and making them more expensive and perhaps riskier for no reason. In that 10-year time period that they tracked riskier for no reason. In that 10-year time period that they tracked, the number of robotic hysterectomy soared and there was a decline in straight-stick laparoscopic hysterectomy. But that was because the laparoscopic surgeons were moving to the robot and then some of the vaginal surgeons were moving to V-notes. So the combination of that was a lot fewer vaginal hysterectomies over time not recovering the endoscopist back to the vagina. So there's just no evidence that folks are moving from endoscopic or robotic to V-notes.
Speaker 3:Now in that same group, 53% of the hysterectomies were done, of course, robotically or laparoscopically. They still had some abdominal hysterectomies as well. They were interested in what factors were influencing surgeons to pick a different route of hysterectomy. But I think that the mistake here was assuming that people were picking routes for rational reasons, like I'm going to do this laparoscopically because of the patient's comorbidities. People just do what they do. I think Whatever route they do, they tend to do.
Speaker 3:They did, of course, note that vaginal hysterectomy had a significantly shorter operative time and shorter length of stay than the other routes and a much lower cost than the other routes.
Speaker 3:They also conclude that all the minimally invasive routes have a very low complication rate and that it's unlikely that robotic hysterectomy or endoscopic hysterectomy would provide an appreciable or clinically significant improvement in perioperative outcomes, since basically all three of the minimally invasive rates meaning laparoscopic, robotic and vaginal already have really low complication rates. People are used to comparing these routes of hysterectomy to abdominal hysterectomy and I think that was how we talked 20 years ago and we've gotten the complication rates down for all three methods fairly low, and so it does come down to rarer outcomes and cost and time and you really need a randomized controlled trial to understand some of these differences. That somehow accounts for surgeon variability and technique variability. To make more commentary and this of course, is a retrospective data collection but they point out that, as I said, 53% of the patients in the low-risk group had endoscopic hysterectomies, again for no rational reason, given the candidates that they picked, and that this gave them unnecessary abdominal wall incisions and potential risk for abdominal wall defects and higher costs and a longer surgery.
Speaker 2:And also increased risks for coptahiscence. You and Maddie were talking about that last time.
Speaker 3:Right, and a paper like this wasn't really able to capture some of that. But yes, unfortunately they didn't have that in there. The other part I thought was interesting, though, was how they look at the costs, and so they have a discussion about turnover times and costs. So most studies, when they talk about the cost of robotic hysterectomy, they don't include any attributable cost to the purchase and maintenance of the robot, but rather just focus on the cost of the consumables that are used. For the case, the cost of OR time seems to be one of the most important and largest expenses, and some studies will estimate that cost in. But, of course, vaginal hysterectomy in every study is significantly shorter than these other methods, even for the same candidates, which is the nice thing they did here, which showed with these what we'd call simple patients, how much quicker vaginal hysterectomy still was. But there's also the issue of how that operative time is calculated. Our time is $45 to $60 a minute, and so every minute and how you calculate that's going to make a big difference in cost.
Speaker 2:Yeah, and you can see this issue even in your local hospital with how turnover times are calculated. So does surgery time start when the surgeon starts with their first incision to when they finish their last stitch, or does it start when the patient enters the room A lot of times that's listed as anesthesia time and when the patient leaves the room? Because when there's a difference in positioning and prepping time with different routes of hysterectomy, then those times outside of just like incision to stitch are also going to be quite different. So while it might look like your operative time isn't that bad, if you're also losing 15 or 20 minutes on just positioning and prep, then you're still losing OR time that you could have used for other things.
Speaker 3:Yeah, so they actually suggested this idea that instead of calculating from incision to last stitch, as is commonly done, instead you look at, for example, how many hysterectomies of a certain type vaginal, robotic, laparoscopic, abdominal can be done in your operating room on average per day in your allotted block of time, so that you're including the total operating time plus the time in between, which might be longer for the robot than with the other routes of hysterectomy. Certainly anecdotally that's what people say there is this time when the patient's not in the room that's spent repositioning the robot, changing the instrumentation, draping the arms, all these things done before the patient's brought into the room. So you do typically see longer turnover times with the robot.
Speaker 2:Yeah, so maybe you could do four straight vaginal hysterectomies in an OR day in one room but then only two or three robotic hysterectomies in that same amount of time. But that might not be reflected in just the standard surgeon time skin to skin.
Speaker 3:Yeah, exactly. And so then that effectively drives the cost up another 25 to 50% when you're thinking about how you're blocking out OR time and things like that. Now, of course, if you're marketing robotic hysterectomy, then you're going to prefer the incision to last stitch time estimate and you're going to highlight your very best robotic surgeons, not your average robotic surgeons, and you're going to want to calculate the cost without including the cost of the purchase and maintenance of the robot that's attributable to its use for that surgery. So I thought it was interesting in the question why vaginal hysterectomy why not vaginal is always pertinent, and actually there is an article in the July Green Journal that just came out we both just got this the day before recording Current and future trends in the performance of vaginal hysterectomy in the United States, and this is a really good article too, and the quick summary of it is that they're estimating that, unless something changes by 2030, vaginal hysterectomy is estimated to be used in only 11.9% of patients undergoing hysterectomy for prolapse and in 3.5% of hysterectomies for other indications.
Speaker 2:Wow.
Speaker 3:So that's the current trend and they look. This is also a retrospective cohort study where they looked at over 1.5 million patients, and the only thing I don't like about the study is that they define they use the term minimally invasive hysterectomy to mean robotic or laparoscopic, not vaginal, and vaginal hysterectomists would take some issue with that, because vaginal hysterectomy is the most minimally invasive route of hysterectomy, but in any event, it's a wonderful article, and they also they discuss the concerning trend that even among the urogynecologists, they're doing more and more non-vaginal surgery as they adopt things like the robot for sacrocopopexy and things like that which don't have a firm evidence basis.
Speaker 3:So I think that the lesson of both of these articles is that we're not choosing the route of hysterectomy for rational, evidence-based reasons, and we're probably choosing them based upon marketing.
Speaker 2:Yeah, those are pretty low numbers for it to be the preferred route for benign hysterectomy whenever possible. Which?
Speaker 3:they still point out in this article. They still point out that it's the preferred route. And years ago I can't remember the exact year, but there was an editorial in the Green Journal, which I start my book with, that was entitled Vaginal Hysterectomy and Apparent Exception to Evidence-Based Medicine and nothing's changed. I think it's been about 20 years since that was written and people have been sounding the alarm for the death of vaginal hysterectomy. But it is getting to a crisis point, I think, and V-notes is what V-notes is, but it's not a substitute for vaginal hysterectomy and it's probably not the thing that revitalizes vaginal hysterectomy, because it just seems to be cannibalizing. It's getting the interest of vaginal surgeons, not of laparoscopic or robotic surgeons, for the most part.
Speaker 2:Well, I'm glad we were able to get to that article this time. Why don't we wrap it up?
Speaker 3:Yeah, we that article this time. Why don't we wrap it up? Yeah, we're in season 10, and you'll be back in a month. Next edition, though, we're going to have Scott Guthrie back on, hopefully, and we're going to talk about some neonatal resuscitation and other neonatal concepts that OBs are interested in.
Speaker 2:All right Awesome.
Speaker 3:See you then.
Speaker 2:See you then.
Speaker 1:Thanks for listening. Be sure to check out thinkingaboutobgyncom for more information and be sure to follow us on Instagram. We'll be back in two weeks.