Episode 7.10 Risks of Multiple Cesareans, Tips for Vaginal Hysterectomy, and Listener Questions

In this episode, we discuss four tips for managing the deeply impacted fetal head at the time of Cesarean. Then we discuss the optimal route of hysterectomy (hint: its a vaginal hysterectomy). Finally, we discuss the obstetric history of the Taj Mahal.

00:00:02 Four Tips For Deeply Impacted Head at Cesarean

Links Discussed

One Too Many?

Maternal Morbidity with Repeated Cesarean Deliveries

In labor urgent cesarean delivery: Comparison of failed TOLAC vs. intrapartum primary cesarean complications

Predicting Uterine Rupture Risk Using Lower Uterine Segment Measurement During Pregnancy With Cesarean History: How Reliable Is It? A Review

Can You Turn a Breech Baby?

Transcript

Announcer: 0:02

This is Thinking About OB-GYN with your hosts Antonia Roberts and Howard Herrell.

Howard: 0:18

Antonia.

Antonia: 0:18

Howard.

Howard: 0:19

What are we thinking about on today’s episode?

Antonia: 0:21

Well, we’re going to maybe finish up our talk about vaginal hysterectomy. I still have a lot more questions to pose to you and I think we also have a listener question we’ll get into. But first, what’s the thing we do without evidence?

Howard: 0:37

How about counseling patients that after a certain number of cesareans it’s unsafe to have any more babies? Or counseling that, after a uterine window observed during a repeat cesarean, that the patient shouldn’t have any more pregnancies because it’s too unsafe?

Antonia: 0:51

Okay, sure. So the idea is that if someone has had three or more cesareans or if you see that thin peritoneal window where there should be uterine muscle during a C-section, then she’s just too scarred up or damaged to carry another pregnancy. So in my mind this might be something that I hear uttered by a surgeon just under their breath during a particularly tough repeat c-section maybe half jokingly, or at least that’s how I interpreted it. Obviously encountering a clear bulging sack out of the uterus, sometimes with no lower uterine segment at all, to even suture shut afterwards, that is a little bit jarring and it feels like maybe you just had dumb luck and narrowly escaped a catastrophic uterine rupture, Like if that little layer had just burst open you’d be in a. You’d be in not a good situation. But if we’re going to formally advise or warn patients not to get pregnant anymore, that carries a lot of weight coming from us as licensed physicians. So I think we have to really tread lightly and carefully here and I can think of a few scenarios where I actually would advise against pregnancy. Maybe you can think of some more. So one would be any kind of advanced cancer that requires treatment ASAP that is going to be harmful to the fetus or anything that just has a really short maternal life expectancy.

Antonia: 2:23

I would say I don’t recommend getting pregnant. Any kind of organ failure that maybe you’re on a transplant list, for example, and more specifically, any kind of severe cardiovascular condition that carries a high mortality risk. That could include maybe a large aortic aneurysm that could burst open at any moment, or pulmonary hypertension, or maybe prior peripartum cardiomyopathy with a low ejection fraction, because those things could all instantly kill the mom and baby so nobody would survive that. Another really rare one might be anaphylaxis to progesterone. It’s more more kind of case report level. And then I’d say anyone that is currently on Accutane or methotrexate or some other kind of teratogenic drug and they’re not ready to come off. So those are the things that for real I would say do not get pregnant anymore.

Antonia: 3:17

But even people that have had a catastrophic uterine rupture, they can still get pregnant again. We just recommend a planned c-section. That’s a little bit earlier than we typically would. And there’s even people out there that have gone through conservative management of placenta accreta and they’ve kept their uterus and they theoretically could get pregnant again. That might be a little higher risk pregnancy. But not even those people are told you’re not allowed to get pregnant, so to say no more babies because you’ve had three C-sections or you had a uterine window, you’re either massively overstating the risks because you’re essentially equating it to something like organ failure, like something that is a lot more serious, or you’re just saying that if you get pregnant again it’s going to be a really hard surgery and I don’t really want to do that hard of a surgery which people have four peats, five peats or whatever you want to call it all the time. So that’s not really as valid of a reason to tell patients that.

Howard: 4:21

Yeah, I think I’ve done a ninth and a tenth Pete I think is my number.

Howard: 4:25

But it’s not that there’s zero risks when you get into that fourth and fifth cesarean and so on. Patients should be counseled appropriately about what the risks are. But if it’s not something as severely life-threatening as cancer or renal failure or something like that where you’d actually consider terminating the next pregnancy to save the mother’s life, well, it’s also not appropriate for us to counsel her against another pregnancy in the first place. So I actually wrote a Howardism about this a few years ago and I’ll put a link to that. But it’s got a couple of graphics there that we can put on, maybe the website or maybe the.

Howard: 4:57

Instagram that really shows the story of the risks that are associated with an increasing number of cesareans, and I think the idea of telling a person that they shouldn’t have more than some number three or four is what you hear a lot. That dates back to the time when most women were having classical cesareans. So remember we discussed a few episodes ago about Jackie Kennedy and one of the remarkable things to the public at that time was that she had, I guess, four cesareans and was allowed to keep on going. Of course her husband was assassinated before the fifth one. But back in the day of routine classical cesareans, meaning a vertical incision, the uterus is built to be so weakened by all of this that after three or so women were really told that they shouldn’t get pregnant again because the risk of uterine rupture was just so high.

Antonia: 5:42

Well I’d say that could make sense. But it’s a good thing that we don’t routinely do vertical incisions on the uterus anymore. So it would be a really improbable thing to run into a patient who’s had two or three or four classical cesareans. They would have all had to be independently indicated, like maybe they had all early preterm deliveries or they lower uterine segment fibrate or something like that.

Howard: 6:10

Yeah, it would be highly unlikely, but that conventional wisdom, as you said, has persisted and so the graphs I’m talking about, which we can again let you see on the Instagram, they show the complication rates per cesarean and for each subsequent cesarean up to the fifth one. So there’s just not a lot of data for numbers six and seven and eight and beyond that has been published that have much statistical validity, but the story of one through five we can see pretty clearly. So the first interesting thing is that the first cesarean delivery, for almost every type of minor and major complication, is more dangerous than the second and third cesarean deliveries and about equal in rate of complications to the fourth cesarean delivery. And after the fourth the fifth one does become a bit more dangerous and one would assume that increases with each subsequent one after that. But the main thing that increases is the risk of hysterectomy with each subsequent cesarean.

Antonia: 7:04

Yeah, so in these charts you listed out a lot of things that we would think that we’d be concerned about, relating to maybe lots of scar tissue dissection, bowel or bladder injury, dvt, wound dehiscence, but actually what plays out? Really the only thing that goes up with multiple cesareans is the risk of abnormal placentation. And even if we looked at average operating times, I’m sure that would be a little bit higher for the repeats, depending on how much scar tissue there is. But usually that’s not enough to clinically affect outcomes and usually those a lot of times, those longer surgeries, are not necessarily in an urgent setting, like if there’s a scheduled repeat C-section reassuring fetal status. We might intentionally just make sure we’re taking our time if we think the bladder is really stuck and we just want to get it out of the way, whereas for an emergent repeat we’ll be more likely to take our chances and just cut through to save the baby’s life and then deal with anything that we might need to deal with afterwards.

Howard: 8:12

Yeah, exactly. Well, if a woman does not have abnormal placentation, she may or may not have had a lot of scar tissue outside of the uterus fascia muscle scar down to the uterus, things like that but the pregnancy will likely continue to be safer than the first cesarean delivery that she had. If she does have abnormal placentation, meaning a placenta spectrum disorder, then she’ll have the risks of a cesarean hysterectomy. And even then, if it’s been appropriately identified beforehand and she has a planned delivery in a place with appropriate resources and personnel, then the risk of major complications are still very low. So the worst complication is maternal death and the rate of maternal death is still higher in the first cesarean than even the fifth. And I’ll also say about hysterectomies I think there is a difference in planned cesarean hysterectomy for placenta accretive spectrum disorder and emergency hysterectomy for a woman who’s been bleeding for 45 minutes or an hour, and that’s our last resort. It’s a much safer procedure the planned one than that emergent one.

Antonia: 9:17

Yeah, and we know how to do hysterectomies because we’re gynecologists and we also know that it is a little bit different to do one at the time of cesarean, whether it’s for intractable bleeding or for invasive placenta. Either way there’s a lot more blood flow. The anatomy might be distorted, in some cases quite significantly. So if we already suspected accreta beforehand, we should have made preparations for even possible massive transfusion, whatever that might be at our facility, maybe having several units cross match blood on standby, or the cell saver, maybe plans for possible iliac vessel occlusion. There’s probably different resources at different places, but we’d want to have everything that we have available nearby and then definitely be set up and ready to do the hysterectomy and other possible organ repairs as needed. So ureteral stents, maybe a cystoscopy tower, stuff for bowel resection if needed, because these can sometimes get out of hand really quickly if you’re not expecting any of it and then suddenly you’re having to send nurses in and out and you’re yelling and frantic. So usually a planned hysterectomy, cesarean hysterectomy, is going to be best accommodated, usually at a tertiary care center that has all those resources and there’s even some places that kind of have programs for management of placenta accreta. They have teams that have set protocols, that, and they’re collecting and analyzing their outcomes and constantly refining their processes. So so that could be a little bit better than just being stuck out in the middle of nowhere, maybe in a rural place that only has a few units of blood at the most. That would not be as good of a situation. But of course you can encounter these unexpectedly too and really do need to be mentally prepared for how you’d handle that, no matter where you are, if you have an OR to do a cesarean in. So that could happen if either it just wasn’t picked up on an antenatal ultrasound or you could have someone come in just off the streets, limited prenatal care and they need an urgent delivery and oh no, it’s placenta accreta or procreta. So I was actually taught that if I get into the abdomen and I see that this uterus, obviously it’s a procreta, it’s completely upside down where the bottom of the uterus is much wider than the top and there’s vessels sprouting out everywhere. If the baby’s okay, then don’t even deliver, just pack her back up and either wait to get all the resources in the room or get the patient transferred somewhere else that does have the resources. Otherwise she very well could just bleed to death, no matter what we do.

Antonia: 12:15

If we just start delivering without being prepared for that, and I’d say the absolute worst case scenario which we still need to be prepared for regardless would be we get in and the baby has to be delivered. It’s a non-reassuring fetal distress and there’s an unexpected procreta that’s maybe it’s already bleeding from everywhere. So I’ve actually encountered that as a trainee. But I was on an oncology rotation, so I came in with the oncologist, they got called in for the room for something like that. And of course it’s one thing to secure uterine vessels that’s still part of our bread and butter with hysterectomies but I’d say it’s another thing entirely. When the placenta has grown up and down, it’s going through the bladder and now the bladder and even the ureters. They’re bleeding too and we have to secure that somehow. So, with all of that said, it is interesting that the risk of death is still higher on average during the first cesarean than even the fifth. So why would this be?

Howard: 13:16

Listening to you talk, you’ve reminded me of another contraindication to vaginal hysterectomy placenta percreta.

Antonia: 13:21

Okay, okay, yep, yep, don’t close up the belly and do that, right yeah.

Howard: 13:26

Don’t go down the vagina. I will say, though, that an energy sealing device is a wonderful thing to have at the time of a cesarean hysterectomy and makes all of this go much smoother, but definitely, as you said, this is something that you need to be skilled to do, but everybody should have the ability to do, hopefully, an emergency cesarean hysterectomy, and all those are excellent points, but I think the reason why, in general, the first cesarean is more dangerous, in terms of mortality at least, is, well, it’s often unscheduled. It’s possibly an emergency cesarean, done after the patient has been in labor for some extended period of time. The head may be very low, the water’s been broken for a while, the cervix is dilated, the anatomy is distorted, and all that distortion of the lower uterine segment increases the risk of extension into the uterine artery.

Howard: 14:12

It increases the risk of ureteric injuries and even other things like retroperitoneal bleeds. And perhaps she’s been laying in bed for 24 plus hours laboring and so she’s at a heightened risk for thromboembolism and infections, with her water broken for that period of time. And all of those risks are much larger in that first cesarean case, and the thromboembolism in particular is often what women die of after a cesarean.

Antonia: 14:39

Yeah, and all of those things can also happen in someone that’s attempting a VBAC too, and now they’ve got scar tissue on top of it. But on average the major complications are still not higher with unplanned repeat C-sections than they are with unplanned primary C-sections. So that’s just maybe a tangent. But another encouraging thing to remember when counseling patients who are considering a trial of labor after one or even two prior cesareans. So okay, so three prior C-sections not a reason to forbid further pregnancies. What about the issue of the uterine window?

Howard: 15:17

Yeah, so this issue about the uterine window was actually a listener question from an OBGYN who listens to the podcast and had a patient come to her recently who had had a uterine window noted in her previous, I think, three-peat cesarean and was told by that obstetrician that she couldn’t have any more babies because she had this window. But I felt like this would go better here as a thing we do without evidence and just being a listener question at the end.

Antonia: 15:44

Okay, that’s fine. Did you at least try to come up with a D or O B name for this listener, or did you just try to sneak out of that?

Howard: 15:53

Okay, I see. Well, you know you’re more creative than I am, but how about weak window from Waco?

Antonia: 15:58

Okay, so there’s a little bit of alliteration there, I guess. B plus on creativity. Alliteration there I guess B plus on creativity.

Howard: 16:07

Alliteration is all I’ve got. Okay, we’ll go ahead then, all right? Well, the medical term for this is actually a uterine dehiscence, but essentially it’s as you described earlier. There’s just serosa covering the separated muscle of the uterus and you can often see the amniotic sac and the fetus underneath it without even making an incision. You can usually just poke your finger through the peritoneum and the amniotic fluid and urine, and you can sometimes suspect this on ultrasound as well, though we don’t currently recommend looking for this routinely.

Howard: 16:32

There’s always been some interest and it comes around every few years in measuring the thickness of the lower urine segment to predict the risk of uterine rupture with prior cesareans, particularly obviously to inform women who want a trial of labor after cesarean. But it’s really amazing how thin the lower uterine segment can be and not significantly increase the risk of uterine rupture. I’ll put a link to a recent article that says essentially that anything greater than two millimeters is probably safe and things less than two millimeters. Well, it’s still not a magic cutoff, but you can counsel folks that two millimeters, less than two millimeters, increases the risk and they might make a different decision about a trial of labor. But if you’ve done a cesarean and you’ve seen a dehiscence or a window.

Howard: 17:17

Well, what do you tell the patient about her future pregnancies? That’s the question here, and really the only thing you can probably tell her that has any scientific support at least is not to have a vaginal birth after cesarean in the next pregnancy and to just plan on a repeat cesarean delivery before the onset of labor. I think the most conservative thing you could do is treat it like a prior uterine rupture or maybe just a prior classical cesarean. But even that’s honestly probably overkill. It’s certainly not supported by sound scientific literature. But we don’t just tell folks with prior classical cesareans that they can’t ever get pregnant again. We just monitor them differently and we deliver them a bit earlier, as you mentioned, and we don’t allow them to have a vaginal birth after cesarean. So to tell someone with an incidental discovery of a uterine window to not have a future pregnancy is just completely unsupported by the literature.

Antonia: 18:09

Yeah, I would think a window is probably less than a millimeter thick, if you can see through it.

Antonia: 18:16

Yeah, all right. Well, let’s get back to vaginal hysterectomy again. If you guys haven’t listened to our most recent episode, listen to that first. So all of the things that you talked about last time with your basic technique, I’ve memorized them and I know them fairly well, but I do occasionally still run into difficulties. So I wanted to go through some things that I still find difficult and frustrating, with some cases at least, and maybe some of our listeners do too and see what good advice you might have as the world expert on the surgery.

Howard: 18:48

Oh my, there you go again.

Antonia: 18:49

Just telling it how it is. So the first thing is visualization. It can sometimes be such a struggle getting the retractors and the lighting just so, and then the weighted speculum falls out over and over again. And right now, generally I have one assistant, but they stand off to one of the sides or sometimes they even stand behind the legs and they’re just holding stuff from, like they’re holding the anterior retractor. They definitely cannot see what I see and invariably if I set one of the retractors where I want it, they’ll almost always shift just a little bit because it’s uncomfortable for them and, of course, because they can’t see what they’re trying to expose. They think they’re standing still, but they’re slowly sliding and I’m just having to continually readjust them.

Howard: 19:39

Yeah, you’re not alone in any of that. I don’t think Most of us have had some problems like that. So let’s see what I can think of that’s helpful here. Let’s see what I can think of that’s helpful here. One thing is definitely candy cane stirrups rather than the yellowfin type stirrups are going to make all of this much, much easier.

Howard: 19:55

Now the weighted speculum popping out. I think that’s actually a fairly easy one to take care of. In the first part of the case, when you’re using a short weighted speculum before you’ve made a posterior colpotomy, if it’s tending to slide out, just have an assistant hold it until you’re done with it. When you have the long-weighted speculum in and you’ve taken the utero-sacral ligaments and tagged them, I’ll take commonly, if this is a problem I’ll take those Vicryl tags that are on hemostats and pull them around the long-weighted speculum to the front of it and then put the hemostat across them or even even twine them up a bit so that the uterosacral tags are actually holding the speculum in place, and then I don’t have to worry about it for the rest of the case until the end. Maybe, when I go back to the short and then again I have the assistant hold it.

Howard: 20:38

You can also sometimes do that with the drape material. If you have a full drape, then you can bunch it up and just take like a towel clamp or something and tag across the drape across the net works too, but tagging the uterodsacrals around it on the front works very well and holds it in high in place for you as you do the case. I’ll also say get two assistants. This is the benefit of having med students, maybe, or something, but if you’re doing this surgery, the surgery is meant to have a surgeon and two assistants, and so it’s just. That’s just just something that that that hospital needs to provide for you.

Antonia: 21:11

Yeah, I’ve tried the thing with the drapes and sometimes that works and sometimes that’s not enough, but I had to try tying them down with the uterus sacral tags. So that’s definitely a great tip I’ll have to remember.

Howard: 21:24

The key to lighting, I think, is having first the appropriate amount of Trendelenburg so that you can get the lights angled into the vaginal cavity appropriately. And then the other thing about lights depending on the type of lights you have is remember to adjust. They all have some sort of center focus, so they need to have quite a bit of center focus and be angled inappropriately. If they have a scatter focus you’re just not going to get light directed, and so you need the angle and the center focus angled into the longitudinal axis of the vagina. So this is a struggle, but it just requires getting them lined up and having the patient in Trendelenburg to take advantage of the beam of focus light that you’re putting down there.

Howard: 22:04

There are a variety of lighted retractors. I don’t have any of those in my hospital. I’ve used them, I’ve been exposed to them, but I’ve never found them incredibly useful, but some people like them. There’s also the option of wearing a headlamp. I’ve done this a couple of times and it can be nice if your hospital has a good headlamp, and they probably do.

Antonia: 22:25

Yeah, I’ve tried lighted retractors before. I did like them, but they were also a bit bulkier, they were a bit thicker and sometimes that was a little counterproductive. But I have had more recent success with headlamps. I think it seems to be easier than getting the overhead lamps aligned just right, and I also I don’t know if I’ve actually checked the center focus issue either the only downside of headlamps is occasionally neck pain if I have to hold my head a certain way.

Howard: 22:54

Yeah, and just to be clear, I rarely use headlamps.

Howard: 22:58

So but but you know, depending on the particular case, it’s available. So, as far as other retractors are concerned, I think this is a question of using, again, the right tools and the right size of retractors at the right times and really just making sure your assistants are doing their job well. So first, you need two assistants, right? So I use a curved Diva retractor anteriorly until I’ve made the anterior colpotomy, because the curvature in that retractor helps to elevate the bladder up and away from the cervix and uterus. And also I do constantly make sure that the assistant has the tip of the retractor in wherever I’m dissecting, because their tendency, as you said, is to just relax a bit and it slides and slips out. So this just takes clear communication with your assistant and making sure that they’re doing a good job of elevating the bladder with that curved retractor or pulling the sidewall appropriately with a right angle retractor. I typically only use one sidewall right angle retractor at a time and we’ll switch it back and forth to whatever side I’m working on. Again, here, teaching your assistant to be mindful of where the tip of the retractor is and to pull adequately is essential. They need to realize that you’re trying to make space up inside of the vagina and that means that the retractor has to be towed in. So I think the retractors aren’t that hard. You’ve got to get them to look in there too.

Howard: 24:21

I also will check with a student or somebody like are you looking at what I’m looking at? And sometimes I chide them a little bit for just staring off at the wall and holding the retractor. I want them looking at what I’m looking at, and sometimes I chide them a little bit for just staring off at the wall and holding the retractor. I want them looking at what I’m looking at, and when I assist my partners with retracting, I always see what they’re seeing, so your assistant can see. They just have to be really anticipating in the surgery.

Howard: 24:41

So I make sure that my assistants are doing what they need to do and also help them with posture and other things like that to make sure they’re comfortable. Like, being a retractor doesn’t have to be a horrible job, but it does require constant feedback for them. I’ve also used the Vaginal Bookwalter retractor and I find that just absolutely absurd, partly because you don’t have the dynamic ability to constantly move the retractors and adjust them as you need and it typically will put both blades in on both sidewalls, and so you don’t have the ability to hunk the cervix and uterus over to the left while you’re working on the right and retracting on the right. I just find that if you can do the case of the vaginal Bookwalter, you probably didn’t need a retractor, so I’m not a fan of that.

Antonia: 25:26

Yeah, I haven’t tried that and I’m not really interested in trying that either, and I don’t think we even have it in my hospital. But you mentioned Curved Deaver and I think that, well, that comes in a default set. That also comes with what I’ll now call the Lucy retractor, renamed Eponym, and that seems to be the default first thing that gets put in the anterior vagina. But I think that’s almost always insufficient, especially for a non-descent case, and they’re short, they’re awkward to hold and they don’t seem to go in far enough. So I typically will just end up switching it out for the Deaver, and I don’t even know why we even start with the Lucy at all.

Howard: 26:08

No, I never do. Don’t have it on my trays. You definitely want a large curved diva and you want large right angle retractors. Another thing that I see done inadequately in this regard and honestly even taught incorrectly by some people who purport themselves to be authorities in vaginal hysterectomy, is how the buttocks are positioned on the table. So remember that the more obese the patient, the more the buttocks are positioned on the table. So remember that the more obese the patient, the more the buttocks need to hang over the end of the table and this changes the angle of the vagina and gives you just a lot more room and it makes a big difference.

Howard: 26:39

So make sure you’re not fighting the table as you try to push the retractor in or dealing with the vagina at too steep of an angle, because the buttocks are too high on the table and it’s always a little bit more falling off the table than people realize. Because when you put the patient in Trendelenburg, especially if the patient is obese, then the patient will roll up the table a bit and so you need the patient hanging off the table really two or three inches if she’s obese, before you start the case. Now, if you’ve already draped and you’re well into the case, but you keep getting held up by the weighted speculum, bumping the table and falling out. You really have to drop what everyone’s doing and move the patient down the bed and then just regown and drape if you have to. It’s really that important and the positioning is everything.

Antonia: 27:25

Yeah, I know sometimes that it feels annoying to interrupt to reposition, but I agree it’s definitely preferable to having that posterior retractor continually fall out. So another thing that’s frustrating to me a lot of the times is that fairly early on in the case I’ll have tagged the utero sacral and then I’m taking bites up the uterus and then the utero sacral tag will come out. Despite my best efforts I’ll have cut through it with my energy sealing device that I used to coagulate and divide the cardinal ligaments. So why does this keep happening? This probably would mess with the trick of tying those tags to the weighted speculum too, if one or even both of them come out.

Howard: 28:07

Well, this definitely happens to the best of us.

Howard: 28:09

But there are two things I think that can be done here. One is to make sure that the sidewall retractor has the uterine sacral suture that you’re talking about behind it, lateral to it, to protect it basically from thermal injury. If it’s happening despite this, then it suggests that there’s not maybe a deep enough circumferential incision around the cervix. Remember, you want to make a very deep incision in that circumferential incision and then elevate the vaginal tissues all the way around 360 degrees cephalad before placing the clamp on the uterosacral ligament, so that all that tissue and that ligament purchase is well away from the next bite. If this elevation isn’t sufficient, then that uterosacral ligament bite will still be relatively close to the first bite of the cardinal ligament or uterosacral cardinal ligament complex that’s left over, whatever your next bite is that you take with the energy sealing device. So I guess the other thing is to make sure that you are really rolling the energy sealing device off of the cervix when you clamp it down.

Howard: 29:11

This is something also that’s not widely taught, but the energy-sealing device should be placed onto the uterine tissue or the cervical tissue in the same way as you would place a steel clamp, meaning that you put it on and it rolls off the tissue. That’s truly the principle of an intrafascial hysterectomy. The other thing I can think of is that a lot of folks struggle because when they’ve taken the uterus sacral ligament they haven’t actually included the whole ligament in the clamp. So after you take the uterus sacral bite, take your finger and put it on the posterior side of the cervix near the torus and, going very high, slide off and see if you still feel any peritoneal reflection there. And getting rid of that reflected peritoneum, which is in fact the real strong part of the uterosacral ligament, is key both to gaining descent early on and to separating the cervix and uterus from the first bite you take with the energy sealing device.

Antonia: 30:03

Yeah, and you’ve talked before about using the right angle clamp, especially in non-descent cases, and using it horizontally or laterally to tent out the peritoneal portion of the uterus sacral ligament so that you can Bovie through that.

Antonia: 30:20

And I suppose if you’ve already been able to at least tag some part of the uterus sacral and there’s not much descent anyway, then it’s probably okay to Bovie through some of it as well, rather than trying to incorporate the entire thickness of the utero sacral ligament into the cuff closure at the end. And the other thing, especially with non-dissent cases, is similarly, I think, to the anterior colpotomy is that the cardinal ligaments also will flatten against the uterus when you’re pulling it down to try to get it, to try to be able to see it better and reach it, so that it’s just flat against the uterine corpus and it’s hard to get a regular clamp around it. Even if you can hook a finger around it, it’s harder to hook a clamp around it and then that kind of that flattened peritoneum keeps holding you up. So yeah, I’d say, tenting it out laterally with that right ankle clamp is a really nice trick. We just need to make sure that we’re only tenting out avascular tissue and we’re not boveing through like an artery with this method.

Howard: 31:21

Yeah, so I call that the right angle clamp technique and it makes a huge difference. I also with the energy sealing device. My first bite often is with the energy sealing device coming up from of the clamp, both pointing straight up, and slide it up beside the cervix to incorporate any remnant of the utero sacral ligament and the cardinal ligament as your first bite, and it makes life so much easier. I think people who struggle with vaginal hysterectomy frequently are just not getting that utero sacral ligament completely transected and therefore they’re not getting the appropriate amount of descent. They make everything else unnecessarily difficult after that. So I’m very aggressive early on about getting descent by completely separating the utero sacral ligaments from the torus of the uterus.

Antonia: 32:21

There’s that word again. You used that earlier the torus.

Howard: 32:25

Yeah, the torus is where the utero sacral ligaments insert at their terminus into the cervix. Maybe we can put a picture of that on the Instagram.

Antonia: 32:34

Okay, well, that’s a new word for me. I learned something today.

Howard: 32:38

I haven’t known it forever, but it’s common among British gynecologists and so that’s where I’ve heard that. But it’s a nice addition to our anatomic vocabulary.

Antonia: 32:47

I guess I’ll keep that in mind if I’m ever operating in Britain. You never know, yeah, who knows, well, okay. Well, here’s another thing that I find difficult I’m sure I’m not the only one After the uterus is out, finding the adnexa either to do just a salpingectomy or, in some cases, a salpingo-oophorectomy.

Howard: 33:08

Yeah, and there’s a lot of literature now about different techniques for finding the adnexa and removing them vaginally. But I also think that this is, for the most part, very easy as well. So I’ll give a couple of recommendations. The first one is, as I mentioned last episode, part of my standard technique of inverting the uterus prior to taking the upper pedicles well, part of what I do there is put an Allis clamp on the fallopian tube, or sometimes a round ligament, if that’s what I can get, before transecting the adnexa from the uterus. So by the time I remove the uterus I have an Allis clamp on the fallopian tube on either side. Then it’s usually a very simple matter to remove the fallopian tube by grasping it with another Allis clamp, using a sponge stick to push away anything important and then using energy sealing device, often in one or two bites if you have the large one, to remove the whole tube. The ovaries are also usually accessible in the same way.

Howard: 33:59

And if this doesn’t work or you’re struggling with bowel coming down and getting in your field of view, or you just can’t find it because you couldn’t grab it or lost it or something, then the other thing to get comfortable doing is just packing the bowel out of the way.

Howard: 34:11

So I take two laparotomy sponges and moisten them, and I take one of them completely unfolded and use that with a ring forceps to wrap around the bowel and push it up and elevate it. And then I take the second one rolled up as a little burrito roll half burrito and I put that in the vagina and once it’s up inside I turn it sideways and then take the right angle clamp and put on that little burrito roll and usually that does a good job of just packing everything away and you’re looking at the whole hollow of the vagina and if you can move that right angle retractor high enough, then the adnexa will usually just fall down into view and whether it’s an ovary or a tube or whatever, it makes things pretty safe and easy then to use your energy sealing device to remove it.

Antonia: 34:57

These are really great tips. We’re on a roll. I’ll definitely have to come back to this episode myself. Well, I have some more, though. My next question this is something that I just want to curse about, but I don’t think I’m allowed to curse on this podcast, right?

Howard: 35:12

There has been a word or two slip in in some previous episodes, but the AI on Apple Podcasts flags it and gives us an adult rating. So we try to be civil here.

Antonia: 35:22

Okay, well, I’ll watch myself then. So let’s talk about the dang anterior colpotomy so you mentioned also in the last episode. This is basically what everybody struggles with probably the most with vaginal hysterectomy but you talk a lot about just not even worrying about it, delay it as long as possible, even till the very end, and that whole concept probably sounds foreign to just generations of training of gynecologists who have been taught that the anterior colpotomy is an essential step. I’ve even seen some tutorials where it’s the first step, even before the circumferential incision, like do it as very early as possible and that you need to do it because it makes or breaks your case, and that you need to do it because it makes or breaks your case. So how do we first, how do we tackle this step? But also how do we get over this obsession with this step, or at least doing it as soon as we’ve been taught to?

Howard: 36:20

do it.

Antonia: 36:21

I don’t think I used any foul language there. No, that was a good job.

Howard: 36:25

You were very restrained. I wonder, though, if the AI would tag Finnish vulgarity.

Antonia: 36:29

Well, that was on the tip of my tongue, so probably don’t tempt me.

Howard: 36:33

You were very restrained, I wonder though, if the AI would tag finish vulgarity. Well, that was on the tip of my tongue, so probably don’t tempt me. Well, as we discussed before, the anterior colpotomy is definitely the hardest part of the case. It’s everyone’s struggle in the normal case. So even folks who do tons of vaginal hysterectomies still struggle and they pause and they slow down at this step, and I think that mastering this step, or at least having a plan of attack that you can work through, is the key to having a safe case that you enjoy doing and don’t get too frustrated with. So I think when people struggle with the anterior colpotomy, the first issue is just not understanding the anatomy as well as perhaps they should, or think that they do perhaps.

Howard: 37:09

So remember, in my basic technique we originally have made that deep circumferential incision and then we’ve elevated the anterior vaginal wall with an Alice clamp. After we’ve gotten some descent, you’ll see some vertical fibers appear and those are the supravaginal septum, and these need to be cut sharply with medicine bomb scissors with the tips turned down towards the cervix all the way across, and then, if you’ve done this in the right plane, a potential space will open up that you can push your finger up into, and that is the vesicocervical space. And somewhere higher up on that vesicocervical space, underneath the index finger, if you’ve stuck your finger up in there, is the reflection of the anterior peritoneum on itself and that’s what forms that classic white line that people are looking for, but it’s often very high. Now, if you cut above that white line, if you cut cephalad to that white line, then you’ve made an anterior colpotomy. If you cut lower down, you have it and it’s hard to see that white line until you have an appropriate amount of artificial prolapse of the uterus.

Howard: 38:20

So routinely, before I ever attempt to cut above that white line, I take the uterus sacral ligaments, as we’ve discussed completely, and when you do that, I take the uterus sacral ligaments, as we’ve discussed completely, and when you do that, the uterus should come down quite a bit If it’s not use that right angle clamp technique we talked about. In fact, I take the uterus sacral ligaments before I even cut into the supravaginal septum and then, after the uterus sacral ligaments, after cutting into the supravaginal septum, then I take the first one or two bites, even above that, including the cardinal ligaments and the uterine artery with the energy-sealing device, before I even think about trying to make an anterior colpotomy. So you just have to take my word for it that, no matter how tempting it might be to go after it, don’t even try to make the anterior colpotomy until you’ve taken the uterus sacral, the cardinals and the uterine vessels on both sides and achieved descent and artificial prolapse of the uterus.

Antonia: 39:14

Okay, okay. But what about when you’re not getting descent because there’s scar tissue, maybe from a cesarean, and you need to get through that? I think that’s where things can really get a lot more difficult.

Howard: 39:28

Yeah, definitely, but the things I said are still true. You still take that initial approach. The difference will be that, after you cut through the supravaginal septum, you may not be in the right plane because of scar tissue and in order to enter that vesicocervical space.

Antonia: 39:44

Hopefully we can put pictures of the anatomy you’re talking about maybe on the Instagram account.

Howard: 39:50

There will be pictures on Instagram, great, okay. So of course, these pictures can illustrate what we’re talking about here, and if you’ve not seen them or not familiar with these anatomic terms, that’s part of the issue. I’ve seen some videos of vaginal hysterectomy on YouTube by teachers of this, and they don’t identify these structures correctly. So people are scared of what they’re cutting into because they don’t know the anatomy that well.

Antonia: 40:10

Well, OK, let’s talk about that scarred down bladder area then.

Howard: 40:15

Yeah, so there’s a whole section in the book about this. But, as with anything, I think you have to get good with the basic technique that we just described and recognize where it varies and understand anatomic variation as it arises and understand when things are different. So I think people struggle here because, again, they don’t necessarily see or know the difference between these potential spaces and they’re worried that they’re going to cut into the bladder constantly. And the truth is, if you understand these planes and you always err on the side of cutting into the uterus or cervix rather than into the bladder, you’re going to be okay. But essentially, I use Sheth’s approach to the difficult anterior colpotomy, which I discussed in my book in which he published towards the end of his career in 2013. So he’s a gynecologic surgeon from India who’s published just an immense amount of the literature about vaginal hysterectomy technique that he’s perfected over thousands of cases and he basically says do these four things for the anterior colpotomy and if they don’t work, then you should convert. He never converts, so you know these four things work. So the first step is basically to do what we’ve just described. So cutting the supravaginal septum bluntly, dissecting into the vesicocervical space after making nice deep circumferential incision and taking the uterosacral ligament. But in this first step he also emphasizes accessing the potential spaces if they’re not obvious from the lateral sides. So in practice I get those cardinal ligaments and the uterine arteries, as I mentioned, with the energy-sealing device, and then I can take a hemostat and find the uterocervical broad ligament space and open that up and that tells me the correct plane to cut into so that I know I’m in the right level. If you will on the cervix, and after you’ve done that, you almost always see the vesicle uterine peritoneum as you get in the right plane. Now, if you can’t, then you can elevate whatever you do have access to upward with a Babcock or an Alice and continue sharp dissection until you get into that space. So that’s his second step.

Howard: 42:21

Now the third step is simply to reach your finger or something around the fundus, and this can be done surprisingly often putting your finger against the backside and then using a Bovie to burn through the remaining connective tissue and make the colpotomy. You really can just keep taking bites along each side until you have enough descensus to reach your tiny little finger around the back of most uteruses fundus. You’re rarely going to get this done in the beginning. And so, again, this is the benefit of delaying this until the end and realizing that’s okay. And yes, sometimes you have to debulk the fundus to do this, but it works quite well and isn’t that hard.

Howard: 43:01

You just grab the fundus with a couple of thyroid clamps and cut a V out of the middle so that you have space to put your finger around there. And then finally, if none of those things are possible, you can always bivalve the cervix and up into the uterus until you run into that reflection of peritoneum and make the anterior colpotomy that way. And this is essentially what I do in these cases and most of the other techniques I talk about in the book I never even use. In fact it’s rare that I do pass the third step. So I would adopt this algorithm and use it consistently, practice it on easy cases, some of the other techniques, and be good at the basics and identifying the anatomy, and then you’ll be fine.

Antonia: 43:44

You make it sound so easy.

Howard: 43:45

Yeah, well, and that’s the issue is that you need someone in many cases to show you some of these things if you’ve not done them. It’s hard to see it in pictures or videos because it involves palpation and recognizing different anatomy as it comes up. But this is the safest way to deal with bladder adhesions. So vaginal hysterectomy, in the published literature, affords a much safer route with a lower rate of bladder, definitely a lower rate of ureter injury, compared to anything being done laparoscopically or robotically, even in the case where there’s been multiple cesareans, and this is the preferred way of dealing with a scarred down bladder.

Antonia: 44:25

Okay, well, we talked a couple episodes ago, I think, about bleeding at the time of C-section and how much bleeding different surgeons are comfortable with, and we didn’t really talk about that too much for vaginal hysterectomy, about that too much for vaginal hysterectomy. But one thing I hate and I’m sure I’m not the only one with this either is a bleeding vessel that’s particularly high up and at the time of vaginal hysterectomy, struggling to identify it and secure it and get control of it. So what are your tips for that?

Howard: 44:56

Well, this goes back to the same question, I think, about visualization and retractors. So make sure that the assistant who’s holding the bladder retractor in particularly really elevates and toes the retractor up so that you’re getting a lot of exposure up top and often the issue will be that bowel’s coming into your view and you’re fighting that constantly and you’re pushing it back with a sponge, stick or two and you still can’t see anything. So when that happens, pack the bowel. It takes 30 seconds in the way that we discussed a minute ago. So practice that and get good at packing the bowel, maybe just to take fallopian tubes or something, so that you’re comfortable with the technique of doing that. Another thing I’ll say about that is I take the little blue tags on the laparotomy sponges and I wrap them around that anterior retractor rather than just push them up in there without anything to hold on to them, because it can be very difficult if you lose, particularly the burrito up inside and you don’t have anything on it, you can lose it pretty easily.

Howard: 45:52

So I always hold on to those little blue tags and I don’t do this all the time, but I am good at it because I do utero-sacral ligament suspensions and I do it every time I do that, and so I can quickly and easily pack the bowel away if I need to get that tuber ovary or if I have a bleed up there and I just can’t see it and I need good exposure. So that’s the key to all surgery, isn’t? It Is getting the exposure you need. You can also take the cystoscope which is probably on your tray not on every time I do a hysterectomy, but it is frequently and it’s right there and you can take it when that bowel’s packed away and look up in the vagina.

Howard: 46:31

And if you have everything packed away nicely, you can, between that and a sponge stick and a long Allis clamp, you can find stuff around the corner of the pelvis pretty easily and you don’t need V-notes or all of the other stuff just to do that. And because you’re using that under visualization and you’re grabbing what you need, you don’t have to worry about blindly sticking a ligature or a stitch up there, for that matter, and causing unintentional thermal ureter injury. That’s, I think, the appeal of V-notes. For a lot of folks is that idea of being able to see those higher bleeds. But we’ve been doing some form of vaginal laparoscopy for years and years, both with and without insufflation.

Antonia: 47:10

Transinflation would be just the light touching organs and like burning organs. But it sounds like if you pack things away then you’re not touching the light all over the bowel and burning anything.

Howard: 47:27

Maybe. But also remember, if you’re doing traditional laparoscopy, how concerned are you if the tip of the light touches small bowel? In fact many of us do that deliberately to clean it off. So the tip of the light does not produce enough thermal injury to cause a problem. It’s the tip of the light cord that does.

Howard: 47:46

So, don’t be afraid of things you shouldn’t be afraid of. I also heard on a recent podcast somebody talk about not wanting to use their energy ceiling devices at vaginal hysterectomy because they were just worried about the steam causing injuries. The steam doesn’t cause injuries, doesn’t get hot enough. The device causes injuries right.

Howard: 48:05

So if you’re touching or have included in your bite bowel or other things that are of concern, then it’s from a direct contact right. But this idea that the steam coming off of it is hot enough to damage your bowel is silly coming off of it is hot enough to damage your bowel is silly.

Antonia: 48:24

Well, this is some really good stuff. I just have a couple more I think we’ve got time for. So sometimes even getting in posteriorly can be a challenge. So if I’m doing a bimanual exam on a patient and her cervix is so high up that I can’t even reach it with my fingertips, and all the way to my thumb joint that’s almost 20 centimeters, and some patients they’re just so high up there Then I know from experience that I’m going to have a better time approaching her entire uterus and everything from above instead of from below.

Antonia: 48:59

Because even that posterior colpotomy maybe it’s a retraction and lighting issue, but even that just doesn’t go very easily. So the V-notes, I haven’t utilized it yet for making that initial posterior colpotomy yet and I don’t know that that’s necessarily recommended. But what would be your tips for a difficult posterior colpotomy? So maybe even besides lack of descent, maybe let’s say there’s a patient with some posterior fibroids that are blocking access to the peritoneum, or maybe adhesions, which you said. Probably don’t try to do a vaginal hysterectomy on someone whose rectum is scarred to the bladder but the uterus I mean.

Howard: 49:46

Well, that’s one tip already. You’ve just acknowledged that’s not a common situation. But hey, if that’s what’s going on, do a laparoscopic hysterectomy, like that’s fine. If we’re talking about applying vaginal hysterectomy to a general population of OBGYNs, not to master fellows of the craft, well, there’s going to be 10 or 15% of cases, something like that, that people are going to do another way, and there’s nothing wrong with a nice quick laparoscopic hysterectomy for the patient you described, and you might even find that her uterus is scarred to the interior abdominal wall or something, and that’s why it’s so difficult. So we don’t have to do the hard ones vaginally, unless that’s something you’re into. But and I also say that if you think there’s an obliterated cul-de-sac and everyone listening to this podcast, then probably should not be attempting a vaginal hysterectomy. I don’t want to get into techniques that could be useful for obliterated cul-de-sacs because, honestly, you probably shouldn’t be doing them. So stick a camera in their abdomen and either do the case as a LAVH or just a total laparoscopic and don’t be a hero. But I think what happens when you have difficulty with a posterior colpotomy usually is that the circumferential incision is too distal, meaning too close to the end of the cervix, and so you start dissecting too distally and the peritoneal reflection is higher than it normally would be, and you actually can just end up cutting and dissecting that reflection away and pushing it further and further away. One thing I do with those sort of poorly descended ones is utero-sacral ligament massage. So if you massage the ligaments with your finger for about a minute before you start, you can often gain another centimeter or two, and that’s important. Sometimes Now the same thing happens anteriorly, where we dissect too deep and we just push the anterior dissection away. But it’s hard to recover from on the posterior side, especially if there’s not good descent of the uterus to go along with that. So if this is happening routinely to you, then you may need to start making your circumferential incision, at least on the backside, a bit higher than you are, meaning closer to the fundus.

Howard: 51:50

If you don’t get in with your first attempt, pause and do something different. So you could take an Alice clamp and try to identify the peritoneal reflection that at that point is probably emanating away from the cervix towards the posterior vagina. Or in some cases you can use the Pelosi technique. So with the Pelosi technique you take a scalpel and just start cutting at about six o’clock on the cervix and you cut from the cervix, the tip of the cervix, down towards the fundus and move along against the cervix and eventually that scalpel blade will run into and cut the reflection of the posterior peritoneum and then there’ll be a little hole there for you that you can then stick meds in or something and make bigger, and this works very well.

Howard: 52:33

In fact, Marco Pelosi advocates that this is how you should do all of them and I don’t do that, and in fact I rarely use the Pelosi technique, but when I’m in trouble Pelosi saves me. But I still think that that should be a rare occurrence. The posterior colpotomy just shouldn’t be that hard if you’re cutting high enough. So again, if you’re routinely having difficulty, you’re probably starting too distal with your incision. If there’s no descent at all, sometimes it’s helpful to use Jorgensens and scissors because they have that really sharp angle of the blades and you can put the tips of them up against the above the lower uterine segment is where you would be and cut into the peritoneum rather than using the slightly curved Mayos and just dissecting it away.

Antonia: 53:17

All right. Well, what would be the best way to know beforehand that the posterior cul-de-sac is obliterated, without doing a laparoscopy up front on everyone? I’m always just afraid that if it already seems to be more difficult to get in posteriorly than I expected, then maybe there’s adhesions there, and then I don’t want to get too brazen and end up cutting into the rectum.

Howard: 53:41

Yeah, so the clinical history here should provide clues, I think, to the possibility of advanced endometriosis or prior PID or something that might’ve caused adhesions like you’re describing.

Howard: 53:52

But for me, using ultrasound preoperatively to look for visceral slide in the posterior cul-de-sac is the best thing you can do. Vaginal surgeons older than me will tell you that they can confidently determine by physical exam at the time of the case if there’s any scarring there. I’m not as confident as they are, to be honest, but they do say that you can feel with physical exam and have a reasonable idea that there’s no adhesions there by how freely things move and even feel the reflection. But I would recommend, if you have any clinical history at all, to suggest an obliterated cul-de-sac that you use vaginal ultrasound preoperatively in a patient you’re worried about and you take the ultrasound probe and you can push the cervix up with it and see the posterior cul-de-sac and see if it has adhesions or if it moves freely. This is a well-described and standard technique for vaginal ultrasonography and it works very well and you should not have doubt whether or not there is adhesions in the posterior cul-de-sac after an ultrasound.

Antonia: 54:47

I did have some older attendings that really pressed hard into doing a bimanual exam in the clinic and then also again in the OR under anesthesia, and not in all cases but at least some cases, cases also doing like a generous rectovaginal exam.

Howard: 55:03

Well, arguably yeah, arguably most patients, not everybody, maybe prolapse patients and things like that, but most patients are going to have had an ultrasound at some point as part of their workup. So that’s just a question of training your ultrasonographers to do that. We should do an episode sometime about vaginal ultrasound techniques for looking for endometriosis and these sorts of things because a lot of us are not dealing with our gut ultrasounds, all that we should be doing.

Antonia: 55:30

Okay, I promise this is my last question then, and we touched on this in the last episode. So this is hard stuff to teach because it’s harder for people to have the same view at the same time, at least if you’re operating high up at the top of the vagina or even higher, and that’s why I think it’s not always taught well in residency or, of course, even after residency, and why more people are comfortable with endoscopic methods. It’s one of the selling points of V-notes is look how easy it is to teach now a vaginal surgery. Really, it’s the laparoscopic portion of it. So how can we get better at teaching just straight vaginal hysterectomy.

Howard: 56:12

I do think. Obviously it’s more difficult to teach. That’s why people aren’t doing it and it requires an especially good teacher, if we’re being honest. But I do take issue, as I mentioned earlier, about the retractors. The student and teacher can have essentially the same view. So, as I said earlier, I assist in a lot of other people’s hysterectomies and I can train my head around and see essentially everything that they can. But I think one of the reasons for that is that my technique emphasizes obtaining early artificial prolapse of the uterus.

Howard: 56:43

I don’t like to spend a whole lot of time high up in the vagina, so we’re not doing this surgery high up in the pelvis, and if you feel like you’re operating up high in the pelvis, then you’re probably doing something wrong about obtaining artificial descent of the uterus early on and not getting those utero-sacral ligaments completely transected. The uterus should be continuously walking out towards us and the only parts that are difficult are those initial steps of getting descent with the utero-sacral ligament divisions. We can talk about other teaching methods. Of course, later we’re going to do an episode coming up about teaching methods and that’ll be an interesting thing too, about how we apply teaching methods to surgery. But obviously this requires something we don’t have right now at OB-GYN and that’s just an investment in training programs, residency training programs and MIGS fellowship programs into vaginal hysterectomy, and that requires people being interested and believing in it, and again, industry unfortunately tends to influence what we’re interested in.

Antonia: 57:41

All right. Well, this was a really great episode, if I do say so myself. A lot of really useful practical tips here, so let’s finish out with a listener question.

Howard: 57:54

Sounds good.

Antonia: 57:56

Okay, Well, I’ve got one here. This is from a listener who happens to be a pediatrician. I’ll skip any other identifying information here and just summarize the question we got. So our listener said I’m 40 years old and healthy and 34 weeks pregnant with my first baby, and I have two questions. Firstly, after listening to your ECV episode, I asked my OB if he would try that in case I ended up being breech, and he really didn’t seem enthusiastic in general, even though I even I mentioned your podcast and your positive outlook on trying it. So fast forward a few weeks and lo and behold, my baby is breech at 30, at 34 weeks now. So is there anything I can do to change this outcome myself? Seems like she’s not confident that she’ll get an ECV and, and specifically, is there any anything that she can do herself that actually has evidence behind it Signed Breach and Bothered from Brooklyn.

Howard: 58:55

We’re big on alliteration here, aren’t?

Antonia: 58:57

we yeah.

Howard: 58:58

Well, first to answer the question, she’s still likely to turn to cephalic by the time she’s 37 weeks. Only about three, maybe closer to 4% of patients are not hit down by that gestational age, but a ton of babies are still non-cephalic at 34 weeks. So hopefully this conversation doesn’t even matter and the baby will just flip.

Antonia: 59:18

Yeah, and one thing that kind of came up was in communicating with this patient is most healthy patients in pregnancy would have no idea at 34 weeks that they’re breached because they’re not getting ultrasounds. So it’s hard to know the true rate of spontaneous version before 36 to 37 weeks. But for her I’m assuming she got the extra ultrasounds because she’s 40.

Howard: 59:39

Yeah, and yeah, that’s an interesting point and again, most people shouldn’t be worried about it because they don’t know at 32, 33, 34 weeks if their baby’s not cephalic.

Howard: 59:47

So all the extra little things that are sometimes sold to them don’t matter. But in this case, up until recently, even for her it wasn’t recommended that she have extra antithetical testing just based upon her age alone, because she mentioned that she was otherwise completely healthy and low risk. You see a lot of unindicated ultrasounds ordered for folks who don’t necessarily have a specific indication, and here’s a way that that potentially could harm patients. It might be the source of psychological harm, for example, like in this case. And here Breach and Bothered from Brooklyn is worried about the position of her fetus when it honestly may not matter yet and is likely to just resolve on its own in a couple, three more weeks.

Antonia: 1:00:24

Right, and I definitely also see my fair share of patients who have been ordered excessive antenatal testing just completely outside of any guidelines. Usually these are patients that are transferring into our practice from somewhere else in the community, like I don’t know. One example is they have the fetal ureteral dilation which it’s recommended to get one repeat ultrasound many weeks later. But I see people coming in getting twice weekly antenatal testing for this. It’s just way overboard. But in this listener’s case she’s 40 and ACOG’s current obstetric consensus guideline on pregnancy over age 35 does recommend antenatal testing for 40 and up, but it’s very vague. It suggests starting at anywhere from 32 to 36 weeks. It doesn’t specify what type of testing or how often, and it does also say that this is a week recommendation. So once-weekly NSTs starting at 36 weeks could be just as consistent with this as could say twice-weekly biophysical profiles starting at 32 weeks. They’re essentially equivalent based on this ACOG statement. And, even more confusingly, all of this contradicts what is still an active ACOG bulletin on antenatal testing that was published before this advanced maternal age consensus. So that antenatal testing bulletin does not recommend extra ultrasounds or NSTs based on maternal age alone and there’s still no evidence that that testing is beneficial and it occasionally can lead to harm or overtreatment.

Antonia: 1:02:11

That newer consensus document that I’m referring to, which also has input from SMFM, is based on the general idea that whenever the rate of fetal demise is above a certain threshold, we should just do extra testing. It doesn’t necessarily mean that that testing actually reduces the rate of fetal demise, so we’ve talked about those concepts before. Regarding the recommendation of testing for obese women as well, the extra testing hasn’t been shown to help, but it’s just something we’re doing because they have a higher rate of stillbirth. So we’ll give our listeners, doctor, the benefit of the doubt on this point that, yes, it was a valid enough thing to do to ultrasound this healthy patient at 34 weeks because she’s 40 years old. But in general, a lot of women are getting extra ultrasounds for other reasons that they don’t need and they may be finding out their babies are breech when it doesn’t matter yet and it’s just causing them unnecessary anxiety.

Howard: 1:03:11

Well, the second part of the question is what can she do about it, if anything other than I guess do an external cephalic version at 37 weeks? And the answer to that is there’s not really a thing you can do to change it yourself. Tons of things have been recommended by folks over the years, but none of them have demonstrated efficacy in clinical trials. By folks over the years, but none of them have demonstrated efficacy in clinical trials. But since a lot of women are non-cephalic and find out about it at 32 to 34 weeks, even through like 3D ultrasounds and things like that, done for pure keepsake reasons and because many of them normally will turn to cephalic by 37 weeks, then the power of anecdotal evidence for something they did, causing that change in the baby’s position, is unfortunately very strong.

Antonia: 1:03:54

So it’s interesting to see all the things that mothers are being told might help turn their babies to cephalic. And of course, in a world where a lot of women are finding out now, for no good reason, that their baby is not cephalic yet at 32 or 34 weeks, then they’re going to turn to Google or TikTok or something and look for things to do after. Maybe after their doctor has unnecessarily scared them about now they’re going to need a C-section for the fetal position because they don’t even offer ECVs. So I also Googled this. I pretended to be a patient with a breech baby and who’s just Googling stuff, and I found an article from parents.com. It was pretty high up in the list of search findings so we’ll post that here if anyone wants to look at it with us. But it’s a little bit audacious what this article is suggesting.

Howard: 1:04:47

Yeah, and it says it was reviewed by an OB-GYN, but, of course, written by a non-physician staffer. And articles like this are all over the internet and they’re dangerous and just part of the misinformation problem. On the one hand, it has lots of good information and says some of the things we’ve already said that only three to 4% of babies will still be breech at term, and it does mention external cephalic version, but it mentions that last, after all the other things that it tells a woman she can do.

Antonia: 1:05:13

Yeah, so the first thing it talks about is sleeping on your side with a pillow between your legs, but then, in the same line, it says but there’s no scientific evidence that supports that. And it does that more, not just on this first point. So it almost seems like the editor went through this list of random stuff that writer included and, instead of deleting the statements without evidence, they kept all the statements and then just added this caveat that there’s no evidence. But what they really should be doing is telling patients that this stuff does not work, rather than promoting pseudoscience.

Howard: 1:05:52

Well, and then they suggest pelvic tilts or inversion positions, like the child’s pose in yoga, or even just walking or kneeling and lunging, and for this they give a link to another website that if you click on it doesn’t actually mention any of those things as a source. So it’s fairly light on validated scientific suggestions.

Antonia: 1:06:13

Well, yeah, and it gets better. So next they suggest listening to music, because that might get the baby moving and grooving and maybe they’ll just do a little flip.

Howard: 1:06:21

Yeah, some of the stuff that you see on these mother websites is just borderline silly. I wonder if certain types of music are better than others or how loud does it need to be, or is there a certain?

Howard: 1:06:33

beat that the baby likes yeah, what does the baby like to dance to? How do we know? And who knew that babies could groove to music in utero and that was also associated with spontaneous version? Does the mother need to be dancing at the same time? I have a lot of questions, and surely there must be some type of music that causes breach presentations. So if you’re cephalic, should you not dance? If it flips babies, maybe it goes both ways. Maybe it makes babies break, dance or do something counterproductive to cephalic version. So I don’t know, stuff like this drives me nuts and is insane, and it’s shameful that this article is in one of the largest mother websites there is. It produces the magazines, it goes in doctors’ offices and it was reviewed by two board certified OBGYNs and it has stuff like this in it.

Antonia: 1:07:21

I feel like they might as well just say like stay alive, eat food, drink water, breathe, try to enjoy life so you can listen to music, and then maybe your baby will flip.

Howard: 1:07:32

Yeah Well, they wouldn’t be wrong about any of those things, but beyond that, they send patients on wild goose chases, I think.

Antonia: 1:07:38

Yeah, I wonder if maybe they’re thinking that a wild goose chase like this might wear the patients down and then eventually they’ll be like. I tried everything on this website. It didn’t work, so I guess I’ll agree to an ECB.

Howard: 1:07:51

Right, or when their baby spontaneously averts. They’ll tell all their friends that it was because they listened to Michael Jackson music or something, or maybe they’re less likely to do the ECV because all of this unproven stuff that doesn’t work is on there and they conclude that the baby didn’t flip with all of those things they tried. So it won’t matter if you do the ECV either. Misinformation and disinformation just shouldn’t be on websites like this.

Antonia: 1:08:17

Yeah, well, there’s still more. So next they suggest acupuncture and moxibustion. Those things have been studied and they do not cause breech babies to flip to cephalic. That’s been demonstrated. But just like with a lot of quasi-scientific recommendations that are out there, the people that promote this are hedging on a theory or maybe even some derivative evidence that it could work. So in this case they’re suggesting that anything that causes muscle relaxation can help a breech baby flip, and that’s, I think, part of the theory behind the Spinning Babies program too. I think a lot of people have heard of that website, but there’s no direct evidence that actually happens. And there’s also no evidence that persistent breech presentation is due to persistent muscle tension in the mother. I think if there was any evidence then I’d be prescribing muscle relaxants to all my patients with breech babies.

Howard: 1:09:17

Yeah, but that’s not the case.

Howard: 1:09:19

Yeah Well, finally, at the end they mentioned external cephalic version, but the article should say that this is the only thing that has any scientific evidence for facilitating breech babies to turn cephalic above just what happens naturally anyway. And speaking of that, to me it’s a red flag that her physician was hesitant about external cephalic aversion, so this just implies he probably doesn’t do them or doesn’t do them that often. Again, the evidence and the ACOG recommendation are fairly clear, which I’ll read from the bulletin about breech. Because the risk of an adverse event occurring as a result of ECV is small and the cesarean birth rate is significantly lower among women who have undergone successful ECV, all women who are near term with breach presentation should be offered an ECV attempt if there are no contraindications.

Antonia: 1:10:05

Yeah, and the only contraindication listed in the bulletin. It would be a contraindication for vaginal delivery. So things we talked about earlier, like placenta accreta or maybe previa or prior classical. So hopefully our listener will either baby will just slip on their own, or maybe she’ll get a version, or maybe she’ll have a cesarean. Hopefully she’ll update us on what happens.

Howard: 1:10:32

We need baby pictures.

Antonia: 1:10:33

Yeah, I know, okay, well, we’re going to wrap up for today. The Thinking About OBGYN website will have links to stuff we talked about, and we’ll be back in a couple of weeks.

Announcer: 1:10:47

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