Episode 11.5 Gray Journal Cesarean Delivery Edition

We unpack the Gray Journal’s special edition on Cesarean Delivery, separating strong evidence from expert habit, and spotlight where technique, culture, and policy collide. From TXA and barbed sutures to better metrics and imaging, we share what to adopt now and what to question. Featuring Maddie White.

• evidence versus expert opinion across the special issue
• TXA at cesarean shows no meaningful outcome gains
• barbed versus braided sutures and the cost of “speed”
• why fundamentals beat gadgets for blood loss and time
• critique of New Jersey NTSV study and outcome framing
• imaging pearls for post‑cesarean complications
• infection prevention steps supported by trials
• history of cesarean steps and why we dropped some
• rising cesarean rates driven by non‑clinical forces
• better classification systems and dyadic metrics
• balancing maternal and neonatal outcomes
• tool use in obesity and cost‑conscious choices

Be sure to check out thinkingaboutobgyn.com for more information, and be sure to follow us on Instagram

0:01 Why A Massive C‑Section Special Issue Matters

3:15 Expert Opinion vs Evidence: Read With Caution

5:44 Safety Basics: Wear Eye Protection

7:46 Evidence‑Based Technique Still Stands

10:55 TXA At Cesarean: Reanalyzing TRAAP2

18:19 Barbed Sutures And The Myth Of Speed

27:30 Operative Time: Fundamentals Over Gadgets

33:54 New Jersey QI Study: Claims And Confounders

42:05 Outcomes Framing: “Cone Heads” And Bias

49:15 Imaging After Cesarean: What To Look For

54:35 Infection Prevention And SSI Takeaways

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Transcript

SPEAKER_01 0:01

Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Maddie White discussing the Gray Journal Special Edition on Caesarean Deliveries.

SPEAKER_02 0:15

Howard.

SPEAKER_00 0:16

Maddie?

SPEAKER_02 0:17

What are we thinking about on today's episode?

SPEAKER_00 0:19

We're going to talk about this Gray Journal Special Edition that's dated January of 2026, although I think a lot of us just received the physical copy this past week or so. But it's all about cesarean delivery. So if you just got this in the mail, it has a lot of different articles in the special edition, some of which are new to this journal, some of which have been published or pre-printed really over the last year or so online. But we'll talk about that and especially some of the new research-based articles. It's pretty huge. It's several hundred pages.

SPEAKER_02 0:49

And they did something like this for vaginal delivery a couple of years ago, too.

SPEAKER_00 0:54

Yeah. Antoni and I talked about some of the articles from that. I think that might have even been two-part, I can't remember, but it was big. One of the things that's interesting about the special edition is that many of these articles are just really invited opinion pieces from people who have historically been thought leaders in our field. They're not necessarily new research articles or new evidence-based systematic reviews. And I think that's important to remember. There are some randomized trials or some at least clinical trials or retrospective analyses and things like that in this special edition, and we'll go through some of those. But just like that edition on vaginal delivery, there's a lot of interesting reads, a lot of review stuff, a lot of what I would call opinion pieces. You might call it expert opinion, certainly. And it demonstrates a lot of neat stuff. There's a lot of great pictures in this edition. But take some of it with a grain of salt. They're not necessarily systematic reviews and they're not all equally evidence-based.

SPEAKER_02 1:52

Aaron Ross Powell So we shouldn't necessarily change our practice just because of something in this special edition?

SPEAKER_00 1:58

I think that's an understatement. In fact, there's a lot of articles that contradict other articles in the same edition because you have people with different opinions who are who are have reasons to be expert opinions stated in this edition, and they don't always agree with each other. So take it with a grain of salt.

SPEAKER_02 2:16

Okay. Well, should we tackle some of the actual trials first then?

SPEAKER_00 2:20

Let's do it. The real clinical trials.

SPEAKER_02 2:23

Okay. I will say, and I fall trapped to this as well, there are lots of pictures of people performing cesareans in this edition, and one thing I noted was that many of them did not have adequate eye protection.

SPEAKER_00 2:36

That's true. Yeah, I noticed that. There are a lot of people very proud of the picture they're in, but but yeah, not a lot of eye protection. So please wear eye protection at the time of cesarean delivery. They're messy. And if you're taking pictures of yourself doing surgery, make sure you're doing what you tell your residents to do.

Expert Opinion vs Evidence: Read With Caution

SPEAKER_02 2:53

Well, a lot of these are expert reviews, and there's lots of historical information and descriptions of techniques by some of the original authors that I think as a resident is really interesting to learn how these techniques evolved through, though that doesn't necessarily mean that they are techniques we could should currently use. There's really nothing in this edition that would suggest that we change from the evidence-based cesarean delivery technique that we've currently been using and we're trying to teach all of our residents. And there are certainly some excellent review articles. In fact, one of them is written by one of the podcast co-hosts.

SPEAKER_00 3:27

Oh, yes. Yes. And we'll talk about that one later. We'll have her on to talk about the article that she co-authored, but looking forward to that too.

SPEAKER_02 3:35

Well, I like that one. But you have to get to about page 310 to find something that counts as new research. And this was a research letter that sought to reanalyze the TRAP2 trial.

SPEAKER_00 3:45

Right. So the TRAP 2 trial was a French study that randomized women undergoing cesarean delivery to receive a dose of tranexemic acid or TXA versus placebo. And this was originally published in the New England Journal of Medicine back in 2021. In that original trial, they found no difference in patient-oriented outcomes of interest, like need for blood transfusion or what they called clinically significant blood loss, but they did find a slight difference in the number of patients whose estimated blood loss was greater than a thousand milliliters. They found also something like a change in a deficit of hemoglobin of 1.2 in the TXA group versus 1.4 grams in the non-treatment group, the placebo group. So that was statistically significant to find that 0.2 gram difference, but it just isn't clinically significant. So after that study was published back in 2001, most of us didn't start using TXA routinely at the time of cesarean delivery. Certainly some did. But the thought for those of us who didn't is that it didn't have any clinically relevant difference in patient outcomes or outcomes that matter.

SPEAKER_02 4:57

Well, this new research letter looks at the same data set. The authors acknowledged that obstetricians are divided about whether to use it since it has potential GI side effects and thrombolic risks. While the study didn't show any patient outcomes of interest that improved. So they were trying to see if there was a high-risk patient group that they could stratify out in the data set that might benefit more to see if selective use of TXA would prove beneficial compared to universal use.

SPEAKER_00 5:24

Okay, and I guess that makes sense, right? It didn't work for the whole group. Maybe it would prove beneficial in a particularly high-risk, high risk for bleeding, that is, population that the original trial didn't focus on. So what'd they find?

Safety Basics: Wear Eye Protection

SPEAKER_02 5:39

They found that the data didn't support any greater benefit among women who were stratified as high risk, and therefore selective use compared to universal use was not beneficial.

SPEAKER_00 5:49

Okay. So we're still that you either choose to use it or you don't. And therefore we likely remain divided. It's not new information anyway, but it could have been a compelling argument to use it universally had they found a difference. I think a lot of this stuff is philosophical. We talk about this a lot with studies. It it is clear that when you give TXA before a lot of different surgeries, there's evidence in several gynecologic surgeries as well, that it will result in a slightly less blood loss. And if you have a large enough study population, you can see a statistically significant difference in that blood loss. But in this case, it was 0.2 grams of hemoglobin. But that's really just not meaningful for patients by and large. Meanwhile, there are tons of other things that you could change in your surgical technique, whether it's cesarean or hysterectomy or some of the other places it's been studied, that would decrease your blood loss in a clinically significant way, or just even work on speed, for example. Like speed of closure of closing your hysterotomy probably has a lot more to do with what your blood loss will be than anything that you could conceive of of giving TXA or something like that. So philosophically, it doesn't make a difference in the patients that need transfusions and how many and things like that. And do we give everybody a drug that has side effects for a fifth of a gram of hemoglobin?

SPEAKER_02 7:14

Okay. Well, that was the first sort of new clinical evidence in this special edition. The next one is on page 331 and is a randomized control trial of stratifix versus vicral for hysterotomy closure and planned cesarean deliveries. They wanted to see if using the barbed suture was associated with less blood loss, and they found no difference.

Evidence‑Based Technique Still Stands

SPEAKER_00 7:36

Well, and there's yeah, that gets actually to the point I was just making. What if that would increase your hysterotomy closure time and all that time you're sitting there watching bleeders if you didn't have to tie that first knot? And so that's what they were clearly trying to do here. And they really wanted to find a difference, I think. They even did a lot of secondary analyses to try to find some difference in blood loss, but alas, they didn't find that it was associated with decreased blood loss. Now, a decreased operative time with Stratifix, they did find, and they said this was 1.8 minutes shorter surgery. But I guess I have the same thoughts about that. Is it worth an additional$30 to$60 to save 1.8 minutes of operative time? Does that time savings, even if it's true and replicated in another prospective study designed to test for it, does it make any difference for the patient? And if it does, why aren't we focusing on a ton of other things, a ton of other ways that you could save time during a cesarean besides that?

SPEAKER_02 8:42

Yeah, and you and I talked about speed and surgery before, and especially for cesarean delivery. There are a lot of things that could save 10, 15, 20 minutes, but people are not always enthusiastic for those modifications.

SPEAKER_00 8:54

In fact, in this edition, I really enjoyed Marco Pelosi's description of the Pelosi cesarean technique and definitely commend it to be read. Now it's not how I do cesareans exactly, although I've certainly learned a lot from both both Marco Pelosi's. I follow the current evidence-based cesarean technique that we've discussed before on the podcast you and I have talked about. But there are a lot of good things in their technique and a lot of good ideas that things were very innovative for the time. But one of the most important points, I think, is that their average operative time when they studied it, as I recall, was 17 minutes. Seventeen minutes. So we discussed that that's a similar operative time to my own for cesareans when I look in Epic and see my report. And the average one may take a few minutes less. Some are 12 or 13 when you're having a good day or even shorter, and some are 20 or 25 when you've got a lot of scar tissue or other problems, things like that. But there are a lot of things that you can do to improve that time metric. And it's probably not going to be switching from Vicral to a barbed suture that's going to be the big difference that speeds you up. Essentially, the gain that you would have there is by not tying two knots at the beginning and end of your hysterotomy. Now, in that study that we're talking about, that's in this special edition, they reported that their mean closure time of their hysterotomy was 5.4 minutes with vicral and 4.1 minutes with stratifix. And their total operative time was 67 minutes with vicral suture compared to 70.5 minutes with stratifix.

TXA At Cesarean: Reanalyzing TRAPP2

SPEAKER_02 10:37

Yeah, which is just way too long. So both of those times are about three times longer than what they should be shooting for. Now I'm not arguing that everyone should be able to do a 17 or 12 minute cesarean, because I think that if some people were trying to do that, people could get hurt. But I certainly think that speed is the goal.

SPEAKER_00 10:57

Right. And you're not going to get faster by switching to barb suture. So if you're already taking over an hour routinely, it's an average to do a cesarean delivery, then I think you've got other fish to fry other than saving a minute, minute and a half by switching suture type. And my point also is that really it shouldn't take 1.8 minutes to tie these sutures. It shouldn't take five minutes to throw a vital suture across the hysterotomy. I I won't even talk about myself, but I think Marco Pelosi would agree that there's does not take five and a half minutes to close the uterus, or it shouldn't. So tying two sutures is a matter of seconds. And like a lot of things, we need to work on fundamental surgical techniques, get those downpacked first, get our fundamentals correct, work on our golf swing before we buy the big golf club. And that's what worries me about stuff like this, where clearly they were trying to show some benefit from switching to a far more expensive type of suture and this crutch of technology or innovation or whatever to improve what may just be fundamentals that need working on. I don't do vaginal hysterectomies or cesarian deliveries in the exact same way that the Pelosi's do, but they're clearly very good surgeons and they have good fundamental technique. And that's why their operative times are excellent for both of those procedures, is because they've got the basics down pat.

SPEAKER_02 12:21

Yeah. And the other thing I will add to that is just in terms of closing the uterus, I almost wonder how much of that time they're talking about is actually the physical throwing of the suture versus staring at your hysterotomy and moving on to the next step. Because I think when we talk about time in cesarean, at least what I've witnessed, I feel like the longest part of time that sometimes I wonder, are we just watching and waiting is when you're staring at the hysterotomy to see if it's going to bleed or not and if you want to move on from that.

SPEAKER_00 12:53

It could be. And that could be an argument for barb suture. One of the selling points is that it more consistently provides tension across the incision. It's not just about not tying knots if you're the salesperson for the product. And so maybe the theory is that by having more consistent pressure across your hysterotomy, you don't have to sit and stare at it as long. You have less need of figures of eight or other sutures that you place because they're still bleeding. But clearly they did the study and they didn't find that. I think people also waste a lot of time putting clamps on the hysterotomy. The let's pick up the posterior and or the inferior and the superior edges with a Pennington clamp or Alice's or something like that and get everything all, and it really just need to pick it up and close it and have it done in a minute, minute and a half, and then your bleeding is stopped. So again, differences in technique, fundamental differences in technique, but the advocates for the suture found that it didn't decrease their blood loss time.

SPEAKER_02 13:49

Okay. Well, still no unbarbed suture for hysterotomy then. Okay, well, right after that is another retrospective study that's listed as an expert review, but is really based upon a retrospective data collection of two cohorts in New Jersey, shout out, that's where I'm from, before and after implementation of a program to reduce unnecessary cesareans, and this reports on neonatal and maternal outcome differences. I've seen this one on social media used as a dig against efforts to lower cesarean rates, because we, of course, know that New Jersey is known for having exceptionally high C-section rates, even in the United States, somewhere up to like 40 to 50 percent sometimes. So I'm sure we'll see this study used a lot in defense of high cesarean rates. But what did they really find?

SPEAKER_00 14:37

Well, tell us something else New Jersey's known for that's really great. The gardens.

SPEAKER_02 14:41

New Jersey Turnpike.

SPEAKER_00 14:42

Is that a good thing?

SPEAKER_02 14:44

We just love our turnpike. Everybody's going 90 on there.

SPEAKER_00 14:47

Oh, okay. So speeders up there, hit heavy feet.

SPEAKER_02 14:51

Yeah. Okay.

SPEAKER_00 14:52

Yeah. Well, they could have entitled this article something about a quality improvement project to reduce was successful to reduce the NTSV rate, the noliparist term uh singleton vertex rate from forty four point eight percent to twenty-eight point two percent, because that's what they actually did. It's an extraordinary drop. And of course, our goal, national goals and leapfrog groups and different people uh for an NTSV rate is even lower than that twenty-eight point two percent, considerably lower. But still, they started out with a NTSV rate nearly double of what our national goals are, and the goals are meant to be stones along the way down the path. They're not the end goal. But the way they framed this article, it sounds like this was a disaster, it was a failure, because they framed it as being associated with an increase in neonatal morbidities. But with all studies and especially retrospective studies like this one, or studies that don't have contemporaneously matched cohorts, we need to remember that association usually doesn't equal causation. And authors of papers like this need to be more cautious in how they present their data and their conclusions with that in mind. So good job, great job on reducing the rate of cesarean, with again a horrible beginning NTSV rate to a more acceptable one, but still subpar rate. Now, what they did was they compared data from a time from 2015 to 2017, that was their pre-intervention group, to a data from 2019 to 2021, which was their post-intervention group, and they had exactly 719 patients in each arm who qualified for this NTSV metric. The patient characteristics were essentially the same. Age was off by a year or something like that. Except one thing I noted is they did start using a lot more mesoprostal for induction of labor and less dynoprostone in that time period between the two cohorts. That might have something to do with their changing cesarean rate as well. If they started doing more effective inductions, that could be a big confounder. Their interventions included educating their providers, obstetricians and midwives, on the modern definitions of active labor and arrest criteria. Remember, this started right after the ACOG released that bulletin on preventing the primary cesarean rate. They also educated patients about the true risks and benefits of vaginal delivery versus cesarean. And they increased the number of midwives that were available to patients and who were midwives became more involved in managing these patients. And when a cesarean was determined to be necessary, they required a second opinion from another obstetrician before proceeding.

SPEAKER_02 17:45

So really there's lots of confounders, honestly. We don't know which of those changes led to the reduction in cesarean. We don't know how much of an impact of switching to mesoprostal would have made a difference in the outcomes. And we certainly don't know how big a difference moving towards a more midwife-led care model versus an OB-led care model might have been causally related to the outcomes that stand out in their analysis.

Barbed Sutures And The Myth Of Speed

SPEAKER_00 18:10

Right. And that's the problem with this kind of data. And there's going to be other things we don't know. Was there a change in the attending physicians and the obstetricians that were working? Did you have some important people retire? Was there a change in neonatology practices or the neonatology staff during that time with different thresholds for admitting patients to the unit or different guidelines and parameters of their own that dictated more care for babies or less care for babies? Was there a huge turnover in the pool of the most experienced labor and delivery nurses? New lots of new graduates or new nurses as older or more experienced nurses retired, new changes in fetal monitoring equipment, like all sorts of things that you don't know about. And that's always a problem with this sort of study. It's always going to be a failure of retrospective analyses or this sort of non-contemporaneous cohort type study. And that's why you really need a randomized controlled trial if you're going to make any claims at all, even suggestions of causality, and you in that trial you're still going to have problems dealing with all those confounders and more.

SPEAKER_02 19:18

Okay, well, now I'm curious. So what were the differences in the neonatal outcomes?

SPEAKER_00 19:23

Aaron Powell Well, there were no statistically significant differences in things like neonatal ischemic encephalopathy or herbs palsy or seizures or intracranial hemorrhages. But the power of the study is going to come into play on all of those sorts of things because there are numeric differences, but they're not statistically significant because in law likelihood the study is underpowered to see such differences. But there were also no differences, statistically significant differences in fractures, shoulder dystosas, or anything like that. There was, however, an increase in cephalohematomas and a huge increase in encapit succidinium. That's hard to say. I don't think I say that enough.

SPEAKER_02 20:08

Wait, so what you're saying is they had more cone heads, something that doesn't even require treatment, but obviously you'll have more of if you have more vaginal deliveries. Was there an increase in the use of the vacuum over this time?

SPEAKER_00 20:21

Yeah, I think it's a fair point. They label I'm gonna say cone head too, because just because I don't want to say cap it sucks at any of them.

SPEAKER_02 20:29

And feel fair to just don't want to sound superior.

SPEAKER_00 20:33

No, I don't want to I don't want to mispronounce it. But it's a fair point that they label this cone heads under birth injury as a category, and they saw a statistically significant increase in that birth injury. So the choice to label a cone head, something that again requires no observ nothing, requires nothing, as a birth injury, is quite interesting and perhaps telling of biases. That difference actually makes up the bulk of the increased injuries, quote unquote, that were noticed. Now, as far as vacuums, good point. I don't know. There were 56 operative vaginal deliveries in the original cohort, and there were 67 in the follow-up group, so not really any different. You didn't see a huge jump in operative deliveries. But I'm not even sure what the breakdown was for forceps versus vacuums. If that was in there, I missed it. Now, none of the other outcomes except for subgaliol hemorrhage, which, by the way, were spelled wrong in the table, they were not any different, statistically speaking. But they, in the text, they casually aggregate a lot of these different things together, and then they claim, even though they didn't have statistically significant power to do so, that they saw an increased risk of neurologic injuries by adding up one thing here, two things here, and just saying that there was a new. Numerical difference. And authors do this a lot. There was a numerical difference, but this wasn't powered to show a statistically significant difference. And that's a problem when you deal with rare outcomes in a study that's underpowered to look at them. Things that is that occur on the scale of one or a fraction of one per thousand or less in a study that only has 719 patients in each arm, well, that's really problematic because if you even have one negative outcome in one arm or the other, well, you could believe that means something when it doesn't. So it's misleading for them to claim that there was an increase in neurologic injuries, which is exactly what they do and what I've seen some social media posters do when their study wasn't powered to detect that and they found no statistical, statistically significant difference with their agreed-upon statistical methodologies.

SPEAKER_02 22:50

Yeah. And the authors did acknowledge that they used AI to write the paper, but it didn't find that misspelling, clearly.

SPEAKER_00 22:58

Yeah. AI was in a lot of these. It was amazing it's amazing how many papers now have some AI part, but it didn't find that subgalia was misspelled.

SPEAKER_02 23:06

So Yeah. They actually had their intern just write that chart out. Yeah. And then that's where the spelling error came in. But also the interventions to lower the rate of cesarean, which they adopted, are themselves based upon randomized control trials that showed no negative neonatal outcomes. So it's really unfair to have one or two problematic deliveries and then somehow blame their efforts to lower their extremely high cesarean rate down to something more normal as the cause. Instead, there should be a root cause analysis of those individual deliveries that were problematic and that sort of thing, one or two deliveries should reflect no problem at all, or could be due to a change in personnel or other systemic failures. So their conclusions, perhaps written by AI, don't seem to be borne out by the data.

SPEAKER_00 23:54

Well, we don't know if the conclusions were written by AI, but we've definitely entered into the world of AI data analysis and AI, look for AI problems and hallucinations in papers now. But yeah, so one or two one bad case may even be counted multiple times in their data set. Imagine one bad case that both contributed to a NICU admission and need for intervention and ischemic encephalopathy and whatever, and they just casually count that as three or four negative outcomes and make conclusions not based upon the statistical analysis in the paper is really problematic. So well, let's go in order through the journal and look for, again, new data. And but I will say as we're going through, in addition to Pelosi's article, there's an article on essential anatomic knowledge for performing routine and complex cesarean delivery, and it's another wonderful one that learners and all of us really should take a look at and make sure we have our anatomy down pat. I'll also add here that they reference in this special edition an article about non-inclusion of the endometrium in one of the lead front articles. And we previously discussed this on the podcast. A lot of the articles in this edition at times emphasize a closure technique that doesn't involve the endometrium. And the lead thought leaders of that are definitely represented in this edition. So we've discussed this before, and this is certainly not something that has a good evidence basis right now. It's fashionable. It's fashionable among many of the authors and perhaps the editor of this edition. But as a brief reminder, it has not been shown to be beneficial to patients in any randomized trial. In fact, the best evidence cited by one of is it by one of the authors in this edition and in a paper that he and his colleagues wrote comes from a single practice's experience of performing 727 cesarean deliveries by a single group of authors who all didn't include the endometrium over decades, really. And then they have outcomes for those patients in their subsequent pregnancies. And none of them include the endometrium for many decades, and so they have this cohort and they didn't have any patients with invasive placentus. So this observation from that group of authors is the basis of the current trend of non-inclusion of the endometrium. But that study, if you want to call it that, a case series of a single group's patients, didn't have a control group. There was no external comparison. And I could do the same thing. I could publish an article about the 1,500 or so cesareans that I've performed in my career, almost all of which have been performed basically in the manner of the evidence-based cesarean procedure that we've discussed, which includes, for me, has always included a single layer full thickness closure. And I could comment that in the 1500 cesareans I've done, I I've not had a patient come back that I'm aware of with an invasive placenta. That's true. I it doesn't mean there aren't any. I there could be some loss to follow-ups, just as they could have some loss to follow-ups. But that's not scientific. That's clearly not how we generate scientific evidence, and we clearly don't change our practice on a single author or a single group of folks' retrospective personal case series without controlled data collection, without controlled groups, and without tracking down all the patients lost to follow-up. And more to the point, we really need a prospective trial.

Operative Time: Fundamentals Over Gadgets

SPEAKER_02 27:29

Right. That's a case series at best, and it's almost just anecdotal.

SPEAKER_00 27:34

Yeah. It's a great place to start science. I had the observation that we don't seem to have this problem, and I wonder if it's the way we do surgery. But what that should do is inform a prospective trial, not just fundamentally change how we do surgery. So but in some of these articles and with some of the older authors, there is a bias towards what I would call the Halstedian surgical principles of careful dissection and careful reapproximation of every layer. Some of the articles really lean into this idea with thoughts about reapproximating even other fascial layers that we don't normally reapproximate. But we abandoned those ideas really decades ago, and we recognize today that Halstead's under understanding of surgical principles was wrong in many ways, and we've moved on. But a lot of folks haven't, and they persist in this careful layer-by-layer reconstructive approach, sometimes using potentially 10 to 12 sutures at the time of a cesarean. Now you compare that with the Pelosi technique that only used, I think, just three sutures for the whole case, they stapled the skin. And again, I don't agree with all of Pelosi's steps, and I don't do the surgeries that way, but you'd be hard pressed to argue that his outcomes aren't great, or their outcomes, there's more than one Pelosi, I realize that when I say it. It's father and son team. And it's work like theirs, which is also featured in this edition, as well as the Stark technique, which is also featured in this edition, another good one to read, especially for the history of it, that showed us that we shouldn't be doing all of this layer-by-layer dissection and reapproximation. So you have to ignore some of this articles that are heavy on the theory that's infused with this idea of defending what I would call a maximally invasive method of surgery. And we've moved away from that to a minimally invasive era that's more evidence-based from and informed by randomized trials, not theory.

SPEAKER_02 29:36

So basically what you're saying is almost anyone can put together a series of several hundred deliveries or cases from their own career and show really good outcomes with whatever they do because the rate of negative outcomes is relatively low.

SPEAKER_00 29:50

Right. And when you do that, you're also like, it's your technique that you're comfortable with. It's your you've selected the time you're going to look at. A good surgeon, by the way, can use a less than perfect technique and show great outcomes. But we need to develop techniques that are widely applicable to surgeons of all skill levels, and we need to measure the effect of those techniques on a large cohort or a population health, if possible, and look at outcomes for patients that matter. I think that the Pelosi's are excellent surgeons, and they could have used many different variations. They could use the techniques I use, they could use the STARK techniques, they could use anything, and they'd still have an average cesarean technique time of about 17 minutes, and they'd still have great patient outcomes. The question is, can we all do that? And what technique best serves the population at large? There's also a famous quote, and I can't remember it right now, but essentially it says if you read a case series of some surgeon and his great outcomes that he had, and it's 412 patients long, and he had perfect cases, no negative outcomes. Well, if you expanded that case series to 414, you'd find two bad outcomes. And the point of that quote is when you do science, you need pre-specified data collection, pre-specified outcomes of interest, and prospective complete data collection, and ideally randomization in order to really do science.

SPEAKER_02 31:17

All right. Well, another article that I thought was really good, especially for residents, was the review on the diagnosis of post-cacesarean delivery complications with imaging techniques. It's always very difficult to interpret CT scans and any other imaging modalities that patient might get after a C-section, which we know because the radiologist will mention it five times. And this was just a really helpful review article about all sorts of complications post-caesarean and how imaging can be used correctly.

SPEAKER_00 31:46

Yeah, I think definitely this was one of the better articles in the whole edition. And it is very difficult to diagnose, especially like abscesses or retained products, which are some of the more common things we're looking for because in a person who's recently had surgery because of just the normal postoperative changes that are there. But it's a really wonderful review. And it also gets into imaging implications of into subsequent pregnancies like placenta accretive spectrum disorders or cesarean scarctopics, things like that. So definitely worth a read. It even gets into future abdominal wall endometriosis, so it's comprehensive and covers all the kinds of complications from cesarean delivery, both short and long term, that you can imagine.

SPEAKER_02 32:28

Yeah. And in the same way, the article by Patrick Duff on infection after cesarean delivery is also probably a must-read for residents in particular.

SPEAKER_00 32:37

Yes. And couple that with the article on surgical site infections after cesarean delivery and a lot of good information. And surgical site infections is a big quality metric now that we're all working on. Different hospital systems are working on because they're getting reviewed over this. And the incidence of surgical site infections, that article notes, ranges from 3% to 15% in the United States. And obviously, we all want to get that number as small as possible. But they review the diagnostic criteria for surgical site infection and along with some nice case presentations of different types of surgical site infections and how they might present and give some general guidelines and whatnot for prevention. So I thought that was very useful, particularly as something that we're all working on from a quality perspective.

SPEAKER_02 33:23

Yeah. And then they have a table for those recommendations. And interestingly, a lot of the recommendations are essentially using the standardized cesarean evidence-based technique that we've been bringing up, which is interesting because many of the other articles are proposing variations to that technique and not necessarily following it.

New Jersey QI Study: Claims And Confounders

SPEAKER_00 33:41

Aaron Powell Yeah, a lot of contradictions in this edition if you look for them. But yeah, for example, they recommend a single layer locked closure of the uterus at cesarean. They recommend not closing the peritoneum, so not this layer-by-layer reapproximation. They recommend not doing intra-abdominal irrigation. They recommend closing the skin with sutures, not staples. And the table itself is just a review from different international organizations, and sometimes they disagree with each other. Different guidelines from Europe versus the United States, from different agencies will disagree where the evidence is mixed. So do look at the individual evidence for the different steps that they mention. And they go through that in the text where they review the evidence for and against a lot of those different steps from an infectious prevention mindset. I also enjoyed an article about the evolution of modern Caesarean delivery because I like the history stuff. I wish it had gone into a little bit more detail about how individual surgical techniques evolved over time, because I think there's a lot to be learned from that. It didn't go into too much detail on specific steps of C-section, but our modern cesarean delivery technique evolved in an era that didn't have prophylactic antibiotics, and it was under the influence of surgical thinkers like Halstead or Howard Kelly, who believed that surgery was really applied anatomy. They believed that careful anatomic dissection, which they learned in the anatomy lab, where they would practice these procedures on cadavers before doing them on live patients, that was the correct approach, and that restoration of all the anatomic layers, you leave everything like you found it was essential and reflected like good technique. So we developed dogmas influenced by that mindset around things like careful tissue handling, careful sharp dissection rather than blunt dissection, careful layer-by-layer reapproximation of the tissue. And some of that is still appropriate in some cases, but the modern cesarean technique, at least, emphasizes blunt dissection and non-reapproximation of surgical layers like the peritoneum and bulk closures as emphasized in the Pelosi or Misgothlotic techniques. And they're at odds with some of those classical surgical dogmas. And I can see that tension in many of the articles written in this special edition by older surgeons who grew up steeped in those dogmas and traditions and very much judged by how well they handled the tissue and how well they reapproximated layers, and they must feel some angst about people younger, people your age who are not who they view as not doing that well, and you can feel that tension in some of that. But when you get down to an individual cesarean step, a surgical step, and you learn its history, you can see why we abandoned many of these steps when we either A developed antibiotics and didn't need that step anymore, or we just did randomized controlled trials that showed it didn't do what we thought it did. So for example, creating a bladder flap in the pre-antibiotic era wasn't done to protect the bladder, it was done to create a peritoneal tunnel from the outside of the abdomen to the uterine wall so that when you cut into the uterus and pull the baby out, the potentially infected fluids and infection could be limited and contained in this peritoneal tunnel, and that was hugely important in an era where there were no prophylactic antibiotics. But the age of prophylactic antibiotics has made that an unnecessary step. But we persisted in creating these bladder flaps even when antibiotics came, but we tended to reinvent a new reason for it, and we said it was somehow to protect the bladder. And you'll still hear that, I'm sure, in many operating rooms around the world today, in many teaching programs, that the bladder flap is a step that protects the bladder. But then we did controlled trials and we learned that no, actually it's associated with more bladder injury, not less. And that was never the reason why we started doing it to begin with. So stop doing bladder flaps. But I really encourage people to understand the history of those techniques if they want to, and then be comfortable with changes and not beholden to any old surgical dogmas. Take the best practices from different techniques and all the evidence available from different trials, and then use that to inform how you perform cesarean deliveries. I've learned a lot from the Pelosi's, I've learned a lot from the Mizgof Lodeck and et cetera, but like, do I do Ms. Goth Loddeck? Of course not. We've learned a lot since then from randomized trials. Do I do the Pelosi technique as they did it? Of course not. But they're a part of this evolution that helped give us that. And that's why reading those old articles is useful too to understand their thoughts and see how this has evolved.

SPEAKER_02 38:30

So what I heard you say is that Holstead and Kelly probably wouldn't like us doing the blunt separation of the rectus muscles that we love to flex our muscles for.

SPEAKER_00 38:39

They would just look with disgust at what they were seeing. And we're only a couple of generations removed from that.

SPEAKER_02 38:45

Yeah. Okay. Well, this is why we have the standardized cesarean technique.

SPEAKER_00 38:49

Yeah. And again, nothing in here I think has moved us away from anything that is essentially in that technique. But curiously, that technique is not featured in this special edition at all.

SPEAKER_02 39:01

So well, the next original research article is on page 569, and it asks the clinical question: why do cesarean delivery rates persistently rise despite evidence-based efforts to reduce them? So this is really a review of 144 clinical studies that the authors found. They conclude that rising cesarean delivery rates are the result of multiple drivers, and I'll just read their summary. The interplay of profit, litigation fears, and social narratives drives unnecessary cesarean deliveries, whereas rights violations and systemic mistrust disproportionately affect vulnerable women and girls.

Outcomes Framing: “Cone Heads” And Bias

SPEAKER_00 39:41

Well, there you go. They do look at this from a very global perspective, and they know that the highest cesarean rates in the world right now, at least for a larger geographic place, is Latin America. Now, I did a talk in Mexico a couple of years ago about the cesarean delivery rates and how to reduce them. And it was originally based on a talk that I've given in the United States, but I realized that the top ten reasons or the things that you might do in the U.S. are completely different than what you might do or the reasons why they have high cesarean rates in Mexico. And so I got pretty deep as I could in the literature, and there wasn't that much of it, honestly, about why cesarean rates are higher in Mexico in particular. And I talked to a lot of Mexican obstetricians that I know about this. And it really wasn't because they were arguing that it was better for clinical care or anything like that, or certainly no scientific motivation for it, but it was very much driven by cultural expectations and economics and financial differences between private hospitals and public hospitals and reimbursement and really just cultural expectations of the women themselves. And in this article, they talk about five core non-clinical drivers, which they were able to identify. The first was medical legal anxieties and defensive medicine. The second was financial and insurance-based incentives. The third was sociocultural preferences and even aesthetic motivations. The fourth was health system weaknesses, including staffing and service delivery inefficiencies. And the fifth was reproductive rights and informed consensus violations. And they also talked about the effect of media influence and digital normalization of cesarean delivery along with provider convenience and scheduling practices and just patient mistrust, especially among marginalized women. So this article takes, again, a more international perspective on some of those topics, but I really appreciate it after the research I did from my talk in Mexico. And it would have been great to read some of this before I went down there, and it definitely is a worthwhile analysis. But we do have data that shows us that all of these drivers they talk about are alive and well in North America. And so we need a lot of systemic reform and tort reform and shifts in cultural understandings about birth, and I mean both in the hospital and at patients writ large, in order to reverse the influence of these drivers and try to have a positive impact on our own cesarean delivery rate.

SPEAKER_02 42:21

Yeah, and I think what's interesting is that the article we already discussed about the cesarean rate in the hospital in New Jersey shows that same problem, though. When they adopted evidence-based practices to try and cut their NTSV rate in half almost, it seems like they were primed to view that as a negative and not a positive. And that bias led them to inappropriate causation assumptions.

SPEAKER_00 42:43

Right. If we're labeling cone head as a birth injury or birth trauma, then we've gone too far for sure. But it's a deeply complicated topic. And I thought this article did a great job of addressing some of that. I think some of the stuff is surprising. We have studies in America that show the impact of the lawsuits on cesarean rates. And states with higher cesarean rates like New Jersey have higher settlement dollars and more lawsuits around obstetrics, like those are strongly correlated. But we also have data that shows that smaller hospitals with poor staffing are more likely to have high cesarean section rates. More people are likely to get scheduled for cesareans in smaller hospitals where staff needs to be used judiciously. And cesareans are more likely to happen at Friday at 5 o'clock because people want to go home. And there's all sorts of economic things. And traditionally, and still in many payment systems, cesarean delivery is financially rewarded more so than vaginal delivery. So there's a lot of stuff that goes into that from all different aspects and all different perspectives. And so it's a good starting point to wrap your head around some of these issues. Now there's another Research letter that argues that our efforts towards reducing cesarean delivery rates are maybe more effective than we thought. So they used, no surprise, a generative artificial intelligence model to do this analysis. And like many of the articles that they report, they did use AI to write and edit the article and perform the statistics. I just thought it was funny that in the declaration where they make that statement, there's a typo. So we might be overly relying on AI for grammar. Please read the article before you publish it. But in any event, we've discussed on the podcast before about when you just look at the sort of top-line analysis of how we're doing with cesareans, we seem to be losing the battle that was ACOG really and took on around 2014 in reducing cesareans, but that might not be correct. And when you realize that we're dealing with a different patient population, and I've made this point before, we have an older and more obese patient population than we did even 10 years ago. And this analysis provides some data to support that and analyze that. So we've taken a step back on some of the guidelines that came out around 2014 because we thought they weren't working and we need to take a new tact in order to try to reduce the rates of cesareans. But I think the way maybe to think about it is if we hadn't been doing this work and implementing these evidence-based practices to reduce inappropriate cesarean deliveries, then we might actually have a cesarean rate today substantially higher in face of the demographic changes that this article highlights.

SPEAKER_02 45:37

Yeah, and they say that just in the last decade, there's been a 25% increase in women over age 35 and a 26% increase in obesity in our pregnant patients. And both of those factors are obviously associated with higher cesarean delivery rate. So when you look at patients in the same demographic, we've had some success in lowering cesarean rates. But when you look at it overall, because those demographics have changed, we simply have a higher cesarean delivery rate.

SPEAKER_00 46:06

Right. And we need to be more specific about how we classify cesarean deliveries in our research studies and track this better. And in fact, the very next article suggests an intrapartum cesarean delivery classification system. And they have 18 years of data that they present that uses a 10 group classification system. So what they've done essentially is they've created a more granular classification system that divides patients into various categories. So you have term versus preterm, noliparous versus multiparous, but induced labor versus spontaneous labor, pre-labor cesareans versus cesareans that occur after labor or induction is started, reach pregnancies versus cephalic pregnancies or other malpresentations, and singletons versus multiparous patients. And there's some subsets to some of these too. So there's actually more than 10, but uh and also whether a person's had a previous cesarean or not. So they end up with 10 classifications and a few subsets. But I like this for research purposes in particular because it allows you to drill down on where are the rises in rates, where are the falls in rates occurring, and label this information better so we can understand where we need to do the work and what's actually occurring. So I would encourage research scientists to adopt this classification system, and that's what they're encouraging too, and we can build it into our data collection systems and have a better understanding about who's getting cesareans and who shouldn't be getting cesareans and where we need to do the work.

SPEAKER_02 47:41

Yeah. And you've also talked before about the limitations of the NTSV rate. So just tracking that number alone isn't going to account for management of non-cephalic pregnancies or twins. It doesn't help us understand efforts regarding trial of labors after C-sections. And of course, it says nothing about women with prior vaginal deliveries who will wind up with a cesarean. But I think the idea of it was that it was a bellwether. We assume if you're doing well with your NTSV rate, then they are also doing well with your other indications, but it's not very precise for research purposes and it doesn't really address the whole problem.

Imaging After Cesarean: What To Look For

SPEAKER_00 48:18

Right. And it also doesn't address neonatal outcomes, nor does it talk about operative vaginal delivery rates for that matter. So the real problem is these maternal outcomes have to always be balanced with neonatal outcomes. And it's possible for a person to have both too high of a cesarean delivery rate and too low of a cesarean delivery rate. It's possible for a person to have too high of an operative vaginal delivery rate and too low of an operative vaginal delivery rate. It's possible for a person to have too high of an induction rate and too low of an induction rate. So just focusing on a single metric will always create some fallacies and perhaps some perverse incentives when you're tracking that metric and you end up doing harm by your metric. So in the same way, I enjoyed the very next research letter, which was entitled Implementation of the Intrapartum Caesarean Delivery Classification System. And this was a prospective observational study, which again argued for using this system to learn where we're falling short. But if we go all the way back to page 46 of this special edition, there's another article that addresses this issue more directly. It's entitled A New Perinatal Quality Measure in the Noliprous Term Singleton Vertex Births, integrating cesarean rate, maternal, and neonatal outcomes into a single maternal newborn dyadic metric. So I'm not sure that what they're suggesting is the final answer, but it's a big step forward. It still doesn't address, like you said, the twins and the breaches and things like that. But it very obviously is a thing we need to do, meaning to connect the maternal and the neonatal outcomes, and we need to have a discussion about where the balances are. So for example, should we do a cesarean to prevent a cone head, or how about 10 cone heads or a hundred cone heads?

SPEAKER_02 50:04

I'm going to say no and no on that one.

SPEAKER_00 50:07

Okay, well let's remove cone head from birth injury then. But where is the balance? For example, we do several hundred cesareans in patients who have active genital herpes in order to prevent one case of herpetic neonatorum, and it's worth it. We decided that's a worthwhile trade-off to do hundreds of cesareans to prevent even one case of that. But we have to acknowledge that there are risks of cesarean delivery to the mother, both now and to her future pregnancies. Another great section of articles, by the way, thinking of future pregnancies, towards the end of this, deals with placenta accretive spectrum disorders. And again, I would encourage residents to look through those. And also, there's an article on the Nausicaa suture, it's Greek, not Japanese, but it's a great review of the various uterine compression sutures that we use, and they present a new one. But my point was anytime we talk about cesarean delivery rates, the balancing measure is always going to be neonatal outcomes. So we have to decide how much morbidity and mortality we are willing to tolerate to expose the mother to in order to reduce morbidity and mortality in the neonatal side of things. And we need a metric that balances those accordingly, and that's what they've proposed. Again, I don't think it's the last word on this, and it doesn't take into account operative vaginal deliveries either and things like that, but but it's a great first start.

SPEAKER_02 51:35

So they have seven rankings from most desirable to least desirable. Obviously, the most desirable outcome is a vaginal delivery with no maternal and no neonatal complications. But part of the goal of this type of analysis is to understand perhaps what the ideal rates are and that will vary with your patient population. Some hospitals have very high cesarean delivery rates because they take care of an incredibly high-risk patient population, and others have a very high cesarean delivery rate for no good reason at all. Unfortunately, this is all still very difficult where some of the worst complications are just rare. A hospital may look at their data for several years and have no maternal mortality cases because you need several thousand deliveries to see that, and maybe many more if the hospital doesn't have high-risk patients. So it's very difficult, but moving towards increased stratification with the 10 group system and then combining it with some sort of metric that tracks both maternal and neonatal outcomes might help us in the future. It'll help us understand what the optimal rates are for each risk group of patients.

Infection Prevention And SSI Takeaways

SPEAKER_00 52:42

That's the goal. We shall see. I don't know, again, that their system's perfect, and I do think that the more we can focus on individual indications for cesarean deliveries, the better off we are when we review this. And that's where guidelines about arrest disorders or active herpes, like I mentioned, or estimated fetal weights that would indicate a C-section or things like that, something that has specificity and can be tested in an individual trial, that's what's helpful. Having real indications and understanding what those indications are. But of course, that goes away with probably the most common stated or unstated reason for a cesarean, which was the fetal tracing. And that's a whole other problem. But it's possible in the future that those guidelines will also be more nuanced in regard to the mother's risk. And what I mean by that is a non-obese, healthy woman with no medical issues or risk factors is at a different risk for complications from cesarean than an obese woman or a woman with, say, a known clotting disorder or other complications. So a cesarean is going to be less of a negative for that healthy woman than it is for the other patient. And so the balance will change, the risk-benefit balance when you compare it to that dyad with the neonate will change. And so this discussion comes up a lot when we think about trials of labor after cesarean. I think healthy women may do well with five or six or seven deliveries, whereas you're just increasingly playing the odds with a less healthy patient or an obese patient. At the same time, their preexisting risks for cesareans are different, especially labor disorders like in obese patients, but also for cesarean secondary to abnormal fetal tracings or other processes because they have preexisting hypertension or diabetes or other problems that affect the placenta and other underlying medical conditions associated with obesity. So it's very complicated, and we've got to stop doing apples to oranges comparisons. But somewhere in the middle of all that is a balance of maternal and neonatal benefit that we're searching for. Anyway, I enjoyed looking through this special edition, which if you received it in the mail, is 710 pages long, but you can see it online as well. A lot of great pictures, definitely lots of good information.

SPEAKER_02 55:00

Yes. And I think for a resident, this is definitely something we're spending some time with. And a lot of the basic science and background articles are very informative with great pictures, including ones of people that need to be wearing more eyewear.

SPEAKER_00 55:13

And some maybe some created by AI, I'm not sure.

SPEAKER_02 55:16

Yeah, who's to say? Okay. Well, I do have one question for you before I go. It's a topic related to cesarean delivery, but it wasn't covered in those 710 pages, believe it or not.

SPEAKER_00 55:26

Ooh, intrigue.

SPEAKER_02 55:28

Okay. Well, I work in a tertiary care facility. At minimum, I have an attending, a chief resident, and a scrub tech assisting me at all times. Not to mention, sometimes I also have a medical student as well. And yet when we get BMIs into the 40s to 60s for C-sections, we take out the pantas retractor and we it has the stickers on it, you put it on their abdomen, and then it has straps that pull their pantis up. So that way you have easy easy visibility of where you're about to make your incision. I remember when I was your med student, one might call me the pantaser tractor system because that was my job. So I'm just curious what your thoughts are on that.

SPEAKER_00 56:09

Well, I'm not for or against anything in life. I think I obviously am very cost conscious. And people for years have taken some rolls of Curlex and some stickers, abdominal stickers, and made their own panace retractor systems. I think the one you're talking about is nicer because you can let the tension up or let it off. You couldn't do that with those. You had to tie the abdomen back and it was just stuck there unless you cut the or untied it or something. But I'm always just mindful of cost and overuse. So I never use anything like this. As you said, the med student is a pantish retractor system. But I'm not against it on principle. I'm always just against overuse. It's the same for self-retaining retractors, which the Pelosi's use, and we're very encouraging of use and innovative in that regard with their cesareans. I don't use them, both because the data about benefit is mixed and because it's an expense that I'm adding to the cost of every cesarean delivery if I choose to do that. But do I ever use them during cesareans? Of course I do. Someone with a lot of scar tissue, someone who I can't exteriorize. Of course I do. So I think it can be a wonderful thing when you use it in appropriately selected patients, and I think it can be a waste of money when you just grab it for everybody with a BMI over some number, 30 or 40. I think not all BMIs are created the same either. You lay some patients back and it's relatively flat and there really isn't much of a pantis. And in the distribution of the adipose tissue is sometimes odd, and a person with a much smaller BMI, you're just struggling. And so use it if you need to.

SPEAKER_02 57:45

Okay. Well, I feel like that's a change in your thoughts that I've heard from you previously. Once upon a time, I remember you telling me that we were making anesthesia's job ten times harder because you were lifting their pantis up and putting it on their chest and causing ventilation issues.

SPEAKER_00 58:00

Yeah, you might in some cases. And that was always a limitation, again, when you didn't have something that you could adjust on the fly, because that's what that's the way we were doing that years ago. And I've had that case where a patient could not be ventilated with all this weight up on our chest. And it would just made more sense to be able to move the pantas dynamically and be able to help your anesthesiologist out. But the system you're talking about is adjustable. So and you can always abandon it, right? You can always get in trouble and do that. And I also recognize that people will be in different situations. You're by yourself at 3 a.m. You need to get a baby out. You might even choose to do a midline incision and not mess with the pantas in some emergency setting like that, if that's what you need given your resources. So do what's best for the patient.

SPEAKER_02 58:50

Well, interesting. I think that is something as residents that we start learning more as you go. The closer you get to being out on your own, you realize one place it's gonna be, one day it's gonna be just me in a situation and my scrub tech on the other side of the table. And how am I gonna be able to get through the difficult case? So something to think about.

SPEAKER_00 59:09

Resources very widely, and you gotta do what you can where you're at when you can do it. So we'll send us questions and other articles that folks thought was interesting in this special edition, and we'll be back in a couple of weeks. Antonia will be here and we'll have something fun to discuss.

SPEAKER_02 59:27

All right. Thanks for having me.

SPEAKER_01 59:29

Thanks for listening. Be sure to check out thinking about obgyn.com for more information, and be sure to follow us on Instagram. We'll be back in two weeks.