Episode 7.9 Deeply Impacted Fetal Head, Route of Hysterectomy, and the Taj Mahal

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

Management of impacted fetal head at cesarean delivery

Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review

Transcript

Announcer: 0:02

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

Howard: 0:17

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 begin a discussion about the route of hysterectomy, and vaginal hysterectomy in particular. That’ll probably carry over to the next episode, and it’s time for a historical tidbit. This time I think you wanted to talk about the history of the Taj Mahal, right? So we’ll try to get to that too. But first we also have our four tips for deeply impacted cesareans, so when the baby’s head is deeply in the pelvis at the time of cesarean. We have talked about this a little bit in the past, mainly when we were talking about the fetal pillow device. And, just as a reminder, the literature does not indicate that the fetal pillow is worth using and it does cost about $1,000 per single use. A study that was the foundation of the FDA clearance for the fetal pillow device in the US was actually retracted this past fall, which makes the already poor evidence basis for it even more bad. But we have four other tips not about the fetal pillow to talk about for this.

Howard: 1:22

Yeah, we discussed the fetal pillow in our two episodes about interpreting scientific literature because it’s a good example if we’re to apply that. That was 7.3 and 7.4. And it just shows an example of some of the mistakes that are made in interpreting literature with, especially with new devices or new drugs. So if you’re interested in that and haven’t listened to those, then please do. Or if you’re using the fetal pillow and it sounds bizarre to you that we’re saying it doesn’t work, then give it a listen. I will say that, regarding that, there’s a new article in the Gray Journal about this topic in the March 2024 edition that concludes that the fetal pillow’s use can’t be recommended at this time until there’s new randomized controlled trials that show some clear benefit and cost effectiveness. And that’s consistent with most of the recent reviews of the fetal pillow.

Antonia: 2:05

So just over 1% of deliveries are complicated by a deeply impacted fetal head, and that’s probably going to grow as a new generation of obstetricians are less comfortable with operative vaginal delivery and are more likely to move to C-section in the second stage. And it might also be growing potentially due to rising rates of obesity, because that does make a deeply impacted fetal head more common as well. As many as about 16% of second stage cesareans will be complicated by a deeply fetal, deeply impacted fetal head. So this is going to be a fairly bread and butter scenario for anyone who does deliveries. So let’s talk about our four tips then. Our first tip is going to be to make your incision on the uterus higher than you think you need to.

Howard: 2:56

Yeah, a lot of the reviews about this topic focus on what to actually do at the time of the cesarean in terms of maneuvers, and we’ll discuss some of those briefly as well. But one of the things that the fetal pillow was supposed to help with was this problem of having extensions into the lower uterine segment and then therefore into the uterine vessels or even into the vagina. But this tip really addresses that issue. So if a patient’s been laboring and she’s completely dilated for a while and she’s been pushing for a while, then that lower uterine segment really thins out and stretches out and elongates. And so when you look at the lower uterine segment at the time of cesarean and you’re making a decision about where the incision should go, you should deliberately go higher. Even when you think you are higher, you should go a little bit higher still and don’t make a bladder flap, because that will distort the reference point, the landmark. But you need to go significantly higher than you think you should.

Antonia: 3:49

Yeah, it’s even going to be a few inches higher than you think that you need to go, because, in comparison to a scheduled, unlabored C-section in this case, where the head is deeply impacted, down below that, that lower uterine segment is has been really distorted and stretched out.

Antonia: 4:08

So if you go higher up it’ll not only prevent most of the tears, the uterus and maybe uterine vessels, but also most bladder injuries, especially if the patient has adhesions.

Antonia: 4:22

But when you see extensions into the uterine artery, they typically come from either the incision being too low and we’ve discussed before how a lot of these are even below the level of the cervix, sometimes they’re in the vagina unwittingly or those uterine artery injuries may come from the operator’s hand inside the incision, then pressing and stretching out the lower edge of that incision like a fulcrum, like they’re cranking their hand against the uterus to try to lift the baby’s head up and they’re just ripping open the uterus more than it needs to be.

Antonia: 5:04

So along those lines, the second issue why some people may not want to make their incision very high is because, well, the baby’s head is low and they know that the higher up the incision is, the lower down they’ll have to reach their hand and lift the head up. There’s more for the head to travel upwards before it can be delivered, and maybe people are actually worried that they’re going to rip the incision if it’s too high up. So they don’t make it high enough. So that will get us into our second tip, which is, once you’ve made your incision, reach your opposite hand across your body to reach for the baby’s head.

Howard: 5:41

Right. So let’s assume you’re a right-handed person and you’re standing on the patient’s right side. In this case, we’ve learned to use our right hand to elevate the fetal head up to the hysterotomy. Now, when you do that, your wrist is essentially perpendicular to the mother’s body and as soon as your hand is around the baby’s head and you drop your elbow, your wrist cranks downward and you can push that uterine incision down with it and therefore tear and cause these problems If you’re having to struggle because the head’s deeply impacted then, that movement will often cause these extensions we’re trying to avoid.

Howard: 6:14

So I usually use my left hand and just for these sections, which is almost then parallel to the mother’s body, as I reach across my chest and I slide that down around the head and pull back to my left to elevate the head up, and this takes away altogether the issue of what people call breaking your wrist and then therefore extending your hand and tearing the incision. So many times you’ll have to switch your hand. I pull it up with my left hand. I still need to put my dominant hand back in once the head is four inches higher and you’ve broken that suction that develops down there, and then you can complete the delivery as you’re normally comfortable doing.

Antonia: 6:50

Yeah, because you can’t get your opposite hand, your left hand, quite as far under the baby’s head to lift it towards the ceiling. You can lift it towards the mom’s head, but then you got to get it out of the uterus so to then lift it up towards the ceiling. You can’t really get under with that opposite hand anymore. So you’re really just restoring the baby back to where they would be in a normal C-section. That’s not impacted.

Antonia: 7:17

And then you put your normal hand, your dominant right hand, the one that’s closer to the mom’s feet. You get that as far under the head as you can and then pull it out of the uterus, but at that point, because the head is out of the pelvis, then you’re not going to tear that uterine incision open anymore because you’ve restored the baby back to that hysterotomy level. So both these first two tips really the higher incision and then using your opposite hand to pull the head up they really focus on preventing complications of uterine extensions. So now our third tip is going to be just what gets the baby delivered. So this third tip is use a rescue algorithm that you can progress through if the extraction is difficult.

Howard: 8:02

Yeah, so the key to a lot of our obstetric emergencies is having an algorithm and a repertoire of different things to do, a progression just like with any code scenario neonatal resuscitation, postpartum hemorrhage or even adult cardiac arrest, for example. So when people get into trouble a lot of times, it’s because they keep trying the same thing over and over again and rather than working on something different, working through a progression of techniques, that can be helpful. So the techniques that you use specifically should be things that you practice and drill with and you feel comfortable doing, and some of them may play to your strengths and you may prefer them and others may not. And there’s not necessarily a gold standard algorithm for this issue that the evidence isn’t firm on that but the main techniques are to use a vaginal hand, or what’s called the vaginal push method. I’ll just say that you should train your assistant to use their whole hand, the palm of their hand, rather than the fingertips, to elevate the head. You don’t want to put all that pressure just with a few tips of the fingers, but rather the palm of the hand, and that’s the main mistake that can go wrong with that, and so you have to train your assistant, whoever that might be.

Howard: 9:08

If you’re still having a hard time, especially with the vaginal push method, you can use something to relax the uterus during the procedure, such as nitroglycerin, which is usually up there in the anesthesia cart.

Howard: 9:19

200 micrograms IV, for example, will cause the uterus to relax and make all of this a lot easier. If you’re struggling and if you’re going back for a C-section for a patient who’s been pushing, or maybe you’ve failed an operative vaginal delivery or, heaven forbid, you’re actually having to do a Zavanelli for a shoulder dystocia and you know the baby’s head will be low, you may not have much time and so prepare for these things in advance. You should have someone push the baby’s head up with the palm of the vagina before you even cut. They can be doing that while you’re getting down to the uterus, and this will help reduce uterine hysterotomy extensions, compared to struggling and failing and then having a vaginal hand push up after you’ve already torn the uterine incision open. Now, besides the vaginal hand, the other two main techniques are reverse reach extraction, where you reach upwards in the uterus and grab the baby’s feet and pull it out and deliver the child as a breech, or the Pat Warden method, which we’ve discussed on here before.

Antonia: 10:12

Yeah, just as a basic recap, the Pat Warden method delivers the arms first, before any other part of the body, and we did go more into detail with that in episode 4.8, where we also discussed more about the fetal pillow. And yeah, you just wouldn’t think that you could get the arms out, then the shoulders, then the torso, then the hips and legs out through a horizontal incision on the uterus, while all the while the head is still in the pelvis. But you really can. You really should just watch some videos on this is all I can say. And just like the reverse breech extraction, once the rest of the body is out and the head is still in the pelvis, at that point you can gently pull the baby back, maybe by their feet or their hips or shoulders, pull them backwards towards the mother’s head, and that generally will release the impaction and they’ll come out easily. Remember, you don’t want to overextend their neck and pull their feet out towards the mom’s feet. Remember, their head is still stuck. But if you just pull them straight back towards the mom’s head, then they’ll usually slide right out. If you need to, you can have a vaginal hand involved at that stage too.

Antonia: 11:21

And the reason the Pat Worden maneuver or even the reverse reach extraction can be. Nice is, if the baby’s whole body is in the uterus and you’re just trying to lift the baby’s head and their entire body upwards in the uterus, you’re limited by the uterine fundus. It might actually be getting in your way, especially if it’s clamping down at all. But if you get the baby’s entire body out first, then there’s nothing that you’re really fighting against. You can definitely pull back way past the uterine fundus to get the baby’s head to slide out. So look up Pat Warden Maneuver if you’ve never seen it before, and just tuck that in your back pocket for one of these impacted head cesareans in the future. So we have one more tip, and that’s our little trick tip, which is don’t end up in the cesarean in the first place if you can avoid it.

Howard: 12:15

Yeah, maybe that should have been the first tip and we won’t dwell on this one. But obviously we’re seeing more of these deep impacted cesareans because folks aren’t doing operative deliveries and preventing C-sections in the first place. So we don’t have time to do a full discussion about that in detail, but it’s clear that on a larger scale we’re not doing as many second stage operative deliveries as we safely could and probably should be doing and we’re trading that for these more really the most dangerous C-sections that most people ever have. So the cesarean delivery has become the modern substitute for forceps or vacuum for many practicing OBGYNs, and that’s a whole other topic. But I would point people to episode 4.12, where we talked about the angular progression, for example. There are ways of increasing our confidence and finding better candidates for safe operative deliveries. But in any event it should stand to reason that many of these deep arrest cesareans are unnecessary. And if it’s that deep in the pelvis to make the cesarean so difficult, well, maybe it should have been pulled out through the vagina.

Antonia: 13:13

Yeah, maybe we’ll talk about that again in another episode and really get into it, but people should also go back to episode 4.12 as an introduction to those ideas. So that was our four tips. Let’s move on to our main topic today, which is vaginal hysterectomy, and I think this is long overdue for us to talk about here. Some of our listeners probably know that you’re an established, bona fide, full-on expert on this. You’ve made some really great video tutorials. You’ve written a surgical textbook on it. So we’ll try to keep this to the typical episode length, but I’m sure we could go on for like a whole day or longer. I do have some questions I want to get to. Even as long as I’ve been paying attention and studying your method, there’s still a lot of nuance to it. So I’ll try to play the reporter and I’m going to be interviewing you about vaginal hysterectomy. Well, shoot then. There’s still a lot of nuance to it, so I’ll try to play the reporter and I’m going to be interviewing you about vaginal hysterectomy.

Howard: 14:08

Well, shoot, then let’s do it.

Antonia: 14:09

Okay. So first question why should someone have a vaginal hysterectomy, rather than abdominal or laparoscopic or robot assisted?

Howard: 14:18

Yeah, okay, that’s prefatory, I suppose, and we won’t answer these questions in a huge amount of detail. Each of these topics I could talk about for a long time and, as you said, we may have to carry these questions over into another episode anyway. But yes, this first question is a question for patients and gynecologists. The answer, and that is what’s the preferable route when you do a hysterectomy? And I can start by saying that we’ll just limit this discussion as well to benign gynecology for the most part. So we’re talking about cancer. That’s a totally different subject, but for benign gynecology, the preferred route of hysterectomy is vaginal, and almost all uteruses can be removed vaginally, as well as fallopian tubes and ovaries as needed, and this isn’t something that’s even really debated by anyone. The issue is just that physicians will say that certain uteruses can’t be done vaginally and that’s why they choose to do it by some other route.

Antonia: 15:10

Okay, so how would you make that decision and how would you advise that all gynecologists make that decision? So I guess follow-up question what’s the difference in terms of complication rates or length of surgery, blood loss or even cost?

Howard: 15:27

Yeah, the thing about hysterectomies in general for benign cases is that they’re really all pretty safe by almost any route that you might choose, and most women are happy with the outcomes and rarely come close to having a significant complication at least so any particular surgeon’s experience with their preferred route of hysterectomy will likely be positive. But that’s why we have to look at clinical trials in order to inform how we make decisions. This is true of anything we do right. Most people have pretty good pregnancies and whether they have a C-section or a vaginal delivery they don’t care that much. But we have to look at clinical trials in larger numbers to see the difference. Most patients do fine if they get pap smears every one, two, three, four or five years and an individual gynecologist isn’t going to be able to see the impact on a population of folks.

Howard: 16:16

If they meaningful differences in complication rates and outcomes, then vaginal hysterectomy, compared to laparoscopic or robotic hysterectomy, has a shorter operative time, a lower rate of vaginal cuff dehiscence, a lower rate of conversion to laparotomy, less blood loss, less bladder injuries, dramatically less ureter injuries, fewer bowel injuries, less febrile morbidity and fewer total major complications. Patients on average experience a quicker return to activities of daily living. They have shorter hospital stays and higher patient satisfaction, and this is consistent. All these things are consistent across multiple studies. There’s a better cosmetic result, since there are no incisions at all on the abdomen, and it’s significantly less expensive than any other route of hysterectomy to do the surgery through the vagina. Now, all those same things are true of vaginal hysterectomy compared to abdominal hysterectomy as well, but that’s usually not what we’re debating in this case. It’s usually vaginal hysterectomy compared to laparoscopic or robotic hysterectomy.

Antonia: 17:22

Yeah, it seems like now the case has been made over the past years for robotic hysterectomy and probably a big part of that is industry push, and now we’ve also got V-notes. There’s a bit of an industry push there and there’s also robotic assisted V-notes which I yeah, I won’t get into that, but these are being pushed as either adjuncts or just alternatives to vaginal hysterectomy.

Howard: 17:49

Well, industry influences this a lot and they influence the published literature and they influence the thought leaders, who are often paid consultants or patent owners or stockholders of companies.

Howard: 17:59

So I will say, before people get too upset with me that on a certain level the goal is just a minimally invasive hysterectomy, and so the common enemy of us all is the open abdominal hysterectomy. But I have to make the case that if we’re going to spend effort learning a procedure, then we should focus on the one that the scientific studies say is best for the patient. So the real disappointment about the way vaginal hysterectomy is approached in the United States to me is that many doctors in practice will spend a lot of time and effort and we spend a lot of money too proctoring and trying to do labs and things like that sponsored by industry, usually cadaver labs to get better at robotic or laparoscopic or even V-notes cases and expose then their patients in real life to a long learning curve that takes maybe years, or at least dozens of cases, to really be good at it, and initially they’ll have slow cases and long and tedious surgeries.

Howard: 18:59

But the vaginal surgeons of the world seem to say why didn’t you put all that same effort and money and time into vaginal hysterectomy so that at the end of your learning curve, you’re doing the preferred thing for the patient? Now there was an analysis of robotic hysterectomy compared to laparoscopic and vaginal hysterectomy, published in 2016 by Swenson and colleagues, and they concluded quote it will be challenging to find a scenario in which robotic assisted hysterectomy is clinically superior and cost-effective and indeed, in addition to having higher complication rates and taking longer with slower recovery, robotic hysterectomy costs almost twice as much as vaginal hysterectomy.

Antonia: 19:37

Okay. So what patients would you say are definitely not candidates for vaginal hysterectomy, when we’re talking about benign surgery?

Howard: 19:48

Yeah. So who gets one and who doesn’t, this does depend upon your own individual abilities, but that’s true for all routes of hysterectomy. There are roboticists who can do some cases that other people have to do abdominally and et cetera. So there is a minimal safe competency that you have to achieve during your training. But even within that there’s so much variation in individual experiences and technique variation and then your own comfort level and things like that. So you may be a decent vaginal surgeon but sometimes you find that you have to convert to a laparoscopic approach or even an open approach, depending on the pathology. But just because some women need a laparoscopic or abdominal approach occasionally doesn’t mean that we should be advocating that every woman should have their surgery done that way. We should use the safest and least expensive method for as many women as possible, and that’s vaginal hysterectomy. So most women who need a hysterectomy for benign reasons can and should have a vaginal hysterectomy.

Howard: 20:45

We did such a good job today of managing abnormal uterine bleeding and pain and other gynecologic issues non-surgically that we don’t do as many hysterectomies as the profession, as we once did.

Howard: 20:55

But hysterectomy is still generally the most definitive treatment for many common gynecologic disorders, and pelvic organ prolapse is a great example, and all those repairs that the patient needs as part of their treatment are best done vaginally, especially for someone who wants to avoid mesh. So it just makes sense that virtually any woman having a hysterectomy for symptoms of pelvic organ prolapse should have a vaginal hysterectomy. And as obvious as that sounds, there are again those, driven by industry, who are making the case that even women who have prolapse should have robotic cases, and we can talk about that another day, but it’s simply not true. I know that hysteropexy has also been described for patients with prolapse who want uterine conservation, although there’s less data on outcomes, especially regarding subsequent pregnancies. But even this can be done vaginally, and I’d go as far as saying if someone has a hysteropexy, then later in life, once a hysterectomy, you could do that vaginally too.

Antonia: 21:49

Yeah, a hysteropexy was not part of the standard core skills required of OBGYN trainees in the US, at least not when I went through, and I don’t think it is now either. I certainly wasn’t taught how to do these. I didn’t get really any volume and training for that procedure and I also don’t get many patients asking for this specifically. So all of my patients that have prolapse and want it fixed also either want their uterus out or are at least neutral and okay with getting their uterus out, and hopefully most people can picture how the uterus would be in the way a little bit of tacking up the uterine supportive ligaments and the upper vaginal support and keeping the uterus there would make it a little bit more difficult to work around. So, yeah, I agree that this essentially is an indication for a hysterectomy, at least classically by our training.

Howard: 22:47

If you’re done with childbearing, yeah.

Antonia: 22:48

Yeah, exactly.

Howard: 22:50

If you’re done with childbearing and you choose a hysteropexy, then you’re just exposing yourself to increased risk of cervical and uterine cancer and abnormal bleeding and pain, etc. For basically the same surgery, particularly when that surgery is done as a vaginal hysterectomy with appropriate repairs so well beyond prolapse. If we’re strictly talking about removing the uterus, maybe for pelvic pain or abnormal bleeding or any other benign indication, then the question becomes what would prevent a woman essentially from having a vaginal hysterectomy and make her need some other route?

Antonia: 23:22

Yeah, because of course you know, with prolapse the uterus is falling out and it’s almost like you’re doing an open case because it’s right there in front of you.

Antonia: 23:30

So for other non-prolapse issues, a vaginal hysterectomy starts off as operating in a tunnel and for a lot of people it feels like that the whole time, and that’s one reason they don’t like to do that route. So the most common factors that would make vaginal hysterectomy at least a little more tricky would be a large uterine size especially if it’s a lot bigger than how wide their vagina is as far as pulling the specimen out, or scarring of the uterus to maybe their abdominal wall or other organs, or even without any of those other issues, just the simple lack of prolapse, lack of descent. So in practice I think a lot of surgeons might try to exclude all patients from vaginal hysterectomy unless they have this tiny uterus that’s basically falling out already, and no suggestion of scarring from prior surgeries or maybe endometriosis or pain that they need to evaluate with a full laparoscopic survey, or even the need to remove one or both ovaries. But that is not what the evidence shows that we should be doing.

Howard: 24:43

Yeah, that’s right, and a lot of folks will say that pelvic pain is an automatic laparoscopy to look for endometriosis or adhesions, for example.

Howard: 24:52

But all the things you just mentioned are simply not evidence-based reasons to avoid a vaginal route.

Howard: 24:57

You could add to that list nulliparity or a narrow subpubic arch, or obesity, or the need to do a salpingectomy or oophorectomy, or maybe the patient’s had a prior cone or leap procedure that’s made the cervix short or things like that that people will often list as reasons.

Howard: 25:16

Now there are two trials published that randomized women undergoing hysterectomy to the vaginal route by default, versus initially choosing another route based upon some algorithm and then seeing how many conversions were necessary. The first, in 1995, was by Kovach, and they didn’t have the benefit then of energy-sealing devices or many of the things that we use today to make vaginal hysterectomy easier. Yet residents in that study were able to remove 89% of the uteruses through the vagina and all of the rest came out simply with laparoscopic assistance. And that same trial method was repeated a few years ago slightly different but similar findings, and study after study shows that these perceived contraindications simply are not barriers, and we don’t have to go into all that today. But the vast majority of women have a uterus that can be taken out through the vagina with very few advanced techniques.

Antonia: 26:10

Yeah, especially if you’re good at morcellation, so pulling the uterus out in smaller pieces, or if you’re using an energy sealing device and you don’t have to tie knots really high up. Those are both part of the secret sauce, even for really big uterus sizes. Exactly yeah.

Howard: 26:28

And things like prior cesarean deliveries are actually dealt with better through the vaginal route than endoscopically. We have better outcomes. So teaching residents some list of criteria or exclusion criteria for making a decision about the route of hysterectomy that includes the things we just mentioned is not evidence-based and just leads to over-utilization of endoscopic hysterectomy. And again, that was shown in this newer trial in 2017 by Schmidt and colleagues.

Antonia: 26:56

Well, we know that you’ve done a bajillion of these vaginally, even really difficult cases, and at this point you can, I think, finish even a really complicated hysterectomy fibroids, three prior sections, no descent faster than most of us can finish a DNC or hysteroscopy or something and you still have really great outcomes. So I don’t think I can overstate this. For people, you’re literally at the pinnacle of excellence for this surgery.

Howard: 27:25

I’ve just never met anyone else Do I owe you money or something?

Antonia: 27:29

Even saying all that, I still don’t think people quite get it how good you are. I’m just trying to give people an idea of this. It’s really just hard for most people to fathom that have gone through a typical training program and seen how hysterectomies are typically done by their other attendings. So you basically can operate on anyone. It doesn’t matter how abnormal their anatomy is. Of course, you restore it to normal as you go and you have a lot of really either, like free videos, blog posts.

Antonia: 28:02

Your book is very cheap. There’s some things you can’t just do totally for free, but it’s basically free, honestly, and you make it sound easy and look easy. So if someone tries to implement this method that you make it look so easy and then they still take longer than 20 minutes doing it themselves or are struggling, then they can get puzzled and frustrated like I’m doing these steps the way this master does them. Why isn’t it working for me? So what I’m getting at is for anyone who is maybe earlier in the learning curve and they haven’t seen any advanced techniques in real life, or at least that they don’t have them down forwards and backwards like you do. Who should we avoid operating on vaginally?

Howard: 28:46

No, I get what you’re saying and I think the frankly DaVinci knows what to tell you about this. Right, they will tell you to do all of your very easy cases until you’ve done 30 or so and to use a technique that is replicated and straightforward and then start adding in more difficult cases, and so that’s just true of surgery in general, and it’s true of this. I will say that virtually everything I do is something that a person can learn, but you may need a teacher or a mentor, but mostly you need time and you need to use good technique and work your way into harder cases. So if you’re trying to expand the numbers that you approach vaginally, well, what are some things you shouldn’t be dealing with?

Howard: 29:25

An obliterated cul-de-sac, posterior cul-de-sac or other severe uterine adhesions or significant extra uterine pathology, like a concerning or large ovarian cyst or a uterus above some size. It’s going to vary by your skill level and experience that you won’t feel comfortable morcellating once it gets above a certain size, and if you don’t know how to morcellate, then you’re, frankly, probably limited to 12 week size or less, Although you can morcellate those 10 and 12 weekers and start to become comfortable with morcellating and then again work your way up. So if you have basic morcellation skills, probably anything 15 or 16 weeks is within your grasp and if you’re really good at morcellation then basically any uterus can be removed vaginally. But the point is to realize that even in listing very basic techniques and excluding all the things I just mentioned, you can still do 85 plus percent of your hysterectomies vaginally and that’s what the literature shows. A person with normal skill set and normal good basic technique not trying to do the more challenging cases should be doing 85 percent vaginally.

Antonia: 30:33

Yeah, and then for the other 15%, instead of just automatically booking them for the robot or laparoscopic or open in your OR, maybe you could even consider referring them to someone else who could do even those cases vaginally. But that is, I don’t think, a common mindset. In OBGYN the more typical decision process would be that I’ll still do it. Well, even I have my limits of benign cases that I would probably want to refer to someone else.

Howard: 31:06

Well, there are people who do other things with higher volume. It may shock some of the listeners or people who know me, but I’ve referred people to Kevin Stepp in North Carolina for endoscopic hysterectomies and when I thought the patient was better served by a master endoscopic hysterectomist then I couldn’t offer her the same outcome. So we’re all different or good at different things and referral and working with colleagues who have subspecialty skills is important.

Antonia: 31:33

Yeah. So if we know that the vaginal route is preferred whenever possible we do know this, a colleague has been saying it for a long time and we know that there’s techniques that we can learn to get around more and more anatomic barriers to vaginal hysterectomy, then why does it still seem like everyone is just focusing on the robot instead? Because I’ve looked at curriculums, for example, for various minimally invasive gyne surgery fellowship programs. At one point I was wondering if something like that could help me advance my vaginal hysterectomy skills in ways that you’ve developed by your own efforts as well. And you would think fellowship that’s exactly what they would be going for is the best minimally invasive gyne skills anyone can have. But from what I’ve looked at, they’re basically just robot fellowships.

Howard: 32:20

I think the answer to that question is the central theme of, honestly, most of what we talk about on this podcast. The robot is still relatively new and it’s flashy and it has sales reps and they’ll come basically live at your hospital and they will become your best friend and it’s appealing because you can see the whole abdomen.

Howard: 32:39

You can articulate your wrist so fancily, you’re sitting unscrubbed at a station and using a robot as extensions of your arms, as a third arm even, that you can control without relying on assistance, and nevermind that the setup can take 20 or 30 minutes depending on your OR team, during which time I would already be done with the vaginal hysterectomy. But forget all that. And of course it sounds advanced and your hospital may be pressuring you to use it because they spend a lot of money on buying a robot and investing in that and they need to have it used in as many cases as possible to distribute the fixed costs of that system and the maintenance fees and all of those things, and so all that creates a perfect storm where the emphasis is there. So we are consistently blind to how much industry influences our decision-making.

Howard: 33:26

At this point we have a relatively mature literature basis about robotic hysterectomy and routes of hysterectomy in general, and the data simply isn’t there to suggest that we should be doing benign hysterectomies robotically by default. Not that there’s not some patient out there who could have it. At the same time, there are now many gynecologists graduating residency programs who don’t really know how to do a hysterectomy without the robot. So then it becomes a self-fulfilling problem where you need the robot, because you don’t know how to do it without it. And the solution to all of this quagmire is that residency programs and training programs and fellowship programs, including the minimally invasive gynecologic surgery fellowships you mentioned they have to make a point of heavily advocating for the evidence-based method of minimally invasive hysterectomy, which is vaginal hysterectomy, and they have to do that, too, at the cost of this comfort zone they’re living in right now with the robot.

Antonia: 34:21

Yeah, in your book you talked about another reason for this robot takeover as well, which is that being all the anatomy magnified on multiple screens not only is reassuring to the surgeon, but it makes it easier for them to teach the procedure, and that’s probably true for just straight stick laparoscopy as well.

Howard: 34:40

Yes, exactly, and also in my book I cite literature from the 1920s and stuff where the argument was being made, that’s why women should all have abdominal hysterectomies with large vertical laparotomies was because everybody can see and the exposure was so great. So, but yes, I think that’s a common argument for endoscopic hysterectomy in general, not just the robot. And paradoxically, it seems to be harder for an attending on the robot to step away from the console and let their trainee work under direct supervision, compared to if they were all standing around the patient on the OR table and handing laparoscopic instruments back and forth. Or they have the dual doc robots now.

Howard: 35:17

Yeah, you can have an assistant, but yeah, I mean the learning curve for attendings on robots and how residents and fellows have been disadvantaged in many training programs over the last 20 years is significant. And it’s one thing to argue, I think, for straight stick laparoscopic hysterectomy for certain patients, and I do think you shouldn’t be graduating from a residency program today if you can’t do a laparoscopic hysterectomy. But it’s another to argue that laparoscopic hysterectomy should all become robotic hysterectomy. So, but yes, when you’re teaching someone, you just see better if you have a laparoscope or a robot and the learner isn’t going to do anything that you don’t have the same view of as they do. So you’re giving constant feedback and approval. But again, I think that’s a bit of a conceit. The truth is, the outcomes accounting for that are still better if the learner does the case vaginally.

Howard: 36:06

There are certain inherent limitations that are based on anatomy and the relationship of the ureter to the uterine artery. For example. That will always make vaginal hysterectomy where you’re pulling the uterus down and out of the pelvis rather than pushing it up and into the abdomen. It will always make vaginal hysterectomy have a lower rate of ureter injury and cuff dehiscence injury, for that matter, because we open the cuff with a cold knife rather than with electrocautery. So no improvements in endoscopic technique are ever going to match the outcomes that vaginal hysterectomy naturally offers, and I honestly don’t beef that much with a good laparoscopic hysterectomist.

Howard: 36:44

I like Kevin Stepp. His skill set’s amazing and people like that are fantastic. A minimally invasive hysterectomy again is the goal, and I’m just making the point that the scientific literature says that vaginal hysterectomy is the better of those two choices for most patients. But I understand that you have to be able to reach and see at least the bottom of the uterus to even get started vaginally. So if you judge that it’s not reasonably attainable, then sure, laparoscopic through the abdomen is the next best plan rather than an abdominal hysterectomy. But a robot in most cases steps back from that minimally invasive goal by creating a procedure that takes longer, costs more and often is more invasive in terms of the number of ports used.

Antonia: 37:26

All right. So let’s say that you’re someone that went through residency where even the attendings were trying to learn robot. They weren’t really even letting trainees learn on that and they were doing cases that should have been done vaginally but they weren’t. So let’s say you went through residency, really did not get very good instruction, and now you’ve just been checked off on the boxes and you’ve graduated, so now you’re out of training. What’s the best way to now learn on your own how to get better at vaginal hysterectomy if you didn’t learn it that well in training?

Howard: 37:59

Well, this really is the problem, right? So people aren’t learning vaginal hysterectomy well in residency and oftentimes, when they do learn it in residency, when they get their numbers well, they’re learning it from the urogynecologist who, frankly, only does easy prolapse cases. There’s a prolapse video of a vaginal hysterectomy on the ACOG YouTube channel and the techniques are wholly inadequate. But they don’t need good technique because it’s already falling out. In fact, they don’t even have to use a posterior weighted speculum during the case because it’s already outside of the body, right? So there’s no emphasis then to learn techniques that will transmit itself well to doing more difficult cases. And so when you go out and go into practice, then a lot of these folks don’t have the techniques they need to do more complicated hysterectomies. And then they’ve also been taught to send all those easy prolapse cases to the urogynecologist. So they’re not even doing those cases because they were told they couldn’t do fault suspensions or things and they have to send them all off. So we’ve really screwed up our educational system in this sense when we let the urogyns be the teachers of vaginal hysterectomy. It’s a completely different pathway and approach when you’re focusing on prolapsed uteruses than when you’re not. The techniques are substantially different. So, yes, we have a lot of folks out in practice who don’t really know how to do vaginal hysterectomy or therefore also how to approach doing case after case and harder cases and getting better at it progressively.

Howard: 39:29

But I would turn the question around and say again what happened when the robot or the laparoscope came into practice? How did all these doctors learn how to do that? Because they didn’t learn it in residency, and some are now, obviously, but 20 years ago. So it’s actually the same approach. Those folks had training curricula including quizzes and simulations, and progressive hand dot experience and cadaver labs and things like that. But the difference, though, is that the vaginal hysterectomy outside of V-notes isn’t funded by industry. Nobody cares, because companies don’t make the kind of money off of it that they make off of these other routes. The answer is through mentorship and hysterectomy courses and cadaver labs and starting out with your easy cases and getting comfortable with the correct technique that works well for all cases, and then adding in harder and harder cases as you progress. So it’s actually the same way people learn to do hysterectomy on the robot.

Antonia: 40:24

All right, well, let’s get into the basic technique that you’ve written about and that you recommend.

Howard: 40:31

Well, I do think that there’s been actually a lot of progress in vaginal hysterectomy technique and that the vaginal hysterectomy that I do and that many of us do today is not the vaginal hysterectomy that was done 20 years ago and certainly not 50 years ago. There’s a lot of reasons for this, and one is the widespread availability of energy sealing devices, which really has fundamentally transformed all hysterectomy technique, but certainly has transformed vaginal hysterectomy. A lot of the technique now focuses on using the energy sealing device and doing that safely to protect the patient from thermal injury. We also just have some different ideas about anatomy in the course of the ureter, for example, than we thought even in the 1980s, and I’ve written about that. But people didn’t understand the relative anatomic position of the ureter in the 1980s correctly, so we had a lot of bad technique emanate from that.

Howard: 41:19

But I have 11 basic steps in the normal technique and then of course there’s all sorts of variations of these depending upon difficulties you might encounter. So I start with a deep circumferential incision with a cold knife. Now I typically infiltrate the mucosa with a local anesthetic and a dilute vasopressor solution before the first incision. Next I make a posterior colpotomy with scissors and tag that with suture, then I mobilize the bladder upwards without even trying to make an anterior colpotomy. And then the fourth step is to divide the uterus sacral ligaments, and I do this with a clamp and use traditional clamp, cut and tie methods so I can hold on to those ligaments for reconstruction of the vagina. At the end of the case I then use an energy sealing device for the rest and divide the cardinal ligament complex and the uterine artery. And all of this gets me more descent very quickly, particularly if you really focus on getting the full amount of the uterocervical ligament divided. Unless the uterus is adhered, they just all fall out. So by the time I am then making my attempt at an anterior colpotomy in the sixth step, that’s going to be fairly easily because I’ve gained all of this descent.

Howard: 42:25

Now, once the anterior colpotomy is made, then the broad ligaments are taken with the energy-sealing device, and then a key thing is that I do that helps promote safety with the energy-sealing device is I deliver the fundus by inverting the uterus before taking the upper pedicles, and this allows the body and the cervix of the uterus to protect the patient’s internal viscera from thermal injury.

Howard: 42:47

And then in the ninth step I take those upper pedicles with the uterus inverted, and so meaning the fallopian tube and the round ligament, whatever’s left and at that point I’ll also usually grab the fallopian tubes with an Alice clamp so that as soon as the uterus is delivered, I have both fallopian tubes in hand and I can go ahead and remove the tubes, as we commonly do nowadays, or the ovaries, if that’s what the patient needs, and then I perform a McCall culdoplasty unless, of course, there are other pelvic floor repairs that need to be done and then finally close the vagina in a vertical manner and I believe this is the most evidence-based way currently to perform a vaginal hysterectomy.

Howard: 43:24

And these techniques can be done, obviously, in a slightly different order, as might be needed for some difficult patients, and altogether combined with other techniques that come up. You can remove virtually anyone’s uterus through the vagina, but this is the backbone that other more advanced techniques emanate from. So this is the basic technique that you should be doing on your easiest cases over and over again, even the prolapse cases where you think you can skip steps and do it in a different order. You should do this way so that you get good at it.

Antonia: 43:55

And we should reiterate the energy-sealing device. It’s not just a surgeon preference shortcut, it’s the evidence-based preferred method to do this right.

Howard: 44:06

That’s right. I heard a podcast recently where a vaginal hysterectomist was talking about why she just doesn’t like to use it, and this isn’t a question of opinion or personal preference anymore. It is associated with less pain, quicker recovery and is overall safer for the patient, with less blood loss, and in most cases it’s more cost-effective due to the amount of time you save during the surgery. So this is the way it should be done. This isn’t really open to debate anymore. It’s an example of an enabling technology and, of course, I wrote about that many years ago and have fought the good fight for convincing older vaginal surgeons that they need to give up clamp, cut and tie and switch to energy sealing devices. But there’s just a lot of mythos about energy sealing devices and, I think, a lot of pride in people’s abilities to clamp, cut and tie, but that pride isn’t teaching your residents the confidence they need to go out and be vaginal surgeons.

Antonia: 44:56

Yeah, in the April 2024 Green Journal there was an article about enabling technologies in vaginal surgery and it sounds like maybe the authors might have read your book, but it was a review on the literature and they talked about how there were some studies where energy sealing devices were compared to other methods and concluded after this systematic review. I’ll read the quote out Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital duration and in pain scores. And this statement was really out of all the different enabling technologies they reviewed, it was the most positive thing they had to say about any technologies and they included discussion about V-notes and endo loops, which are just a suture on a long suture passer thing, and also robotic V-notes. So they reviewed all of that and it was the energy-sealing device that they really had to conclude was clearly beneficial.

Howard: 46:01

Well, I was happy to see that article published.

Howard: 46:02

I didn’t create the idea of enabling technologies in surgery.

Howard: 46:04

I give credit, at least in my own development, to Ted Anderson for that and others, but I’d be glad if a couple of the authors read the book and got the ideas there. But, that being said, the reduced pain associated with energy stealing devices is important because there have been claims that endoscopic hysterectomy is associated with less pain in vaginal hysterectomy, based on a single Italian study that’s been heavily promoted by industry, and what that paper really found was that good laparoscopic surgeons are better at laparoscopic surgery than bad vaginal surgeons are at vaginal surgery and that energy-sealing devices are associated with less pain than clamp cut and tie. So the mistake in studies like that is comparing energy-sealing devices used endoscopically with clamp cut and tie vaginally. So that’s the key finding is that the energy-sealing devices are associated with less blood loss and less pain. So don’t fall for the apples to oranges comparisons. I’m not advocating for clamp cut and tie vaginal hysterectomies on here. You could make a case that laparoscopic hysterectomy is preferable to that. It would be tenuous, but you could do it.

Antonia: 47:10

So what would you say is the hardest step of a vaginal hysterectomy? And how do you do that stuff?

Howard: 47:16

Yeah, no-transcript. And by the time I usually make it, we have considerable descent of the uterus, artificial prolapse, and in many cases I can even put my finger around the uterus, around the back, if I need to find the reflection of the peritoneum that I need to cut through. But for the difficult cases there’s an algorithm I follow and maybe we can talk about that in the next episode, because I think we’re going to run out of time today.

Antonia: 48:04

Yeah, I think we definitely need to continue this on the next episode and maybe spend more time tackling some of the other challenging things in the vaginal hysterectomy technique as well, and, of course, we’ll put a link to a video of you doing a basic vaginal hysterectomy in the manner you just described. So, for anyone who has not already seen that, definitely check it out, bookmark it. Even now, I still rewatch it periodically, but back in my earlier training days I pretty much had it on repeat constantly, so it never gets old, really. And if anyone out there doesn’t have the vaginal hysterectomy book but this is a surgery that you do, you’re learning and you’re going to do then please do yourself a favor and buy it. You can get the Kindle version immediately on Amazon and just start diving into some of these things in more detail, if you’re interested. Maybe sometime we’ll work on an updated edition as well, but really it’s sufficient in its current form, without any discussion of things like V-notes, for example, but that YouTube video really tells the whole story for this basic technique. So before we end, though, I want to at least bring in V-notes a little bit and get some of your comments on there.

Antonia: 49:20

So for those listeners who don’t know, it’s a relatively new surgical product. It’s really come out mainly in the last few years and it allows people to do laparoscopy through the vagina. So when I first heard about it, this was already after residency that and I saw videos about it. The increased visualization and all the benefits of that visualization were very appealing to me. And just recently on this podcast we had an episode about the risks of laparoscopic entry through the abdomen. So just seeing this V-notes technique where I could get the laparoscopic visualization without having to risk the entry through the abdomen and risk things like aortic entry with that initial trocar, that was pretty exciting. So I went ahead and I did the full training course and I started doing them for myself in select cases where I didn’t think that the basic vaginal hysterectomy technique would be that easy, where I thought that this V-notes will really help us, and I’ve built up a little bit of volume and I’ve built up a pretty decent volume.

Antonia: 50:31

At this point I definitely say that I don’t think that it makes hard hysterectomies easy by any stretch, but I do think that, at least for me, there’s cases where I would not have been able to do that surgery vaginally but I did because of V notes. So it does have its limitations. And I do have to wonder am I also sliding down this slippery industry slope that of course there were reps involved and and it wasn’t that expensive of a training course I just paid for it out of pocket and all that. But then I’ve got the reps following me around and saying, like you want to advertise somewhere that you do this, you offer this surgery and bring in more and more patients and use our product more and more. So I know that you don’t care too much for V notes, because you probably don’t. You probably don’t, can’t think of any reason why you would need it, your advanced vaginal hysterectomy techniques that you do.

Antonia: 51:27

But I know that you occasionally do vaginal laparoscopy without necessarily insufflating. So, without going into a whole hours long debate about this, which we maybe can, we can discuss later what are your overall?

Howard: 51:47

just in a nutshell, thoughts about V-notes. Well, first of all, my, I guess, main objection or big objection is cost, and I feel like, if you’re spending the money on the kit, why don’t you just do a laparoscopic hysterectomy? You’re using all the same equipment, basically with a similar to higher expense, and in my opinion it’s actually probably more difficult than just a laparoscopic hysterectomy would be. So if the main purpose of it is to have more confidence in avoiding thermal injuries with the upper pedicles, well that’s a different issue. That’s something maybe we can talk more about on the next episode. But again, the technique done the right way avoids that issue. I’m also a little weary about the anterior colpotomy issue. Either you need to do it like you normally would do for a vaginal hysterectomy, which arguably is the hardest step. And if you can do that, why do you need B-notes? You’re done.

Howard: 52:30

Or if you do the trick where you dissect the bladder up and then use insufflation through the posterior colpotomy to help show you where you can safely make the anterior colpotomy. Well, I just worry about the position of the ureters and the relative position of the uterus. And again, why don’t we just do a laparoscopic hysterectomy if that’s what you needed to do?

Antonia: 52:48

Yeah, but really the only benefit then is you’re not putting in a trocar through the belly. The risk of that injuring the aorta is pretty rare when you’re using correct technique and direct entry and all that. And yeah, with that anterior colpotomy trick I’ve used it you really have to have thinned out the tissue so much that it actually is just one clear cell layer before you put everything in. And then the only reason that the V-note system helps is because it tents it up and shows you the air behind that layer, rather than having that layer pulled flat down against the uterus where you might’ve gotten in. But for the typical surgeon that layer is flat against everything else and it’s hard to distinguish, it’s hard to tent out just with.

Howard: 53:33

Yeah, so you’ve done all, you’ve done all the hard part, and and there I might’ve just stuck my finger around the back and put my finger there and found it and been done it five seconds, and if the uterus was too big to do that, I would just morsel it to the fundus.

Howard: 53:45

We can talk more about that on the next episode. But again, it’s just like where are you gonna invest your time in learning how to just be the master of the anterior colpotomy vaginally, or this? So to me it’s just another distraction from learning good surgery and also substituting the small laparoscopic energy sealing device when you could be using a large handheld, large jaw ligature, or there’s three products on the market. That makes no sense to me at all and it just makes the case harder and take longer with less secure vessels, and I could go on. But this is just, I think, another example in a long string of industry coming to us and inventing a product and then finding a market without evidence.

Howard: 54:25

There are no randomized trials that show that B-notes is preferable to regular vaginal hysterectomy, and the company that makes it inside details. I consulted with them before and told them I thought it was a bad idea. They don’t have studies that show again, head-to-head benefit. So you invent something and then you figure out how to use it, and this is what we’ve done with a lot of things. We’ve done it with a robot, we did it with electronic field of monitoring, we did it with mesh for prolapse. So industry’s job is to invent new things, and our job is to do the trials to figure out where they’re beneficial and where they’re not.

Antonia: 55:05

Yeah, at this point it really does seem like a bridge for people that, frankly, just didn’t get good skills in residency. They’re mainly robotic surgeons or laparoscopic and they want to figure out how they can learn to do vaginal cases well laparoscopically, because that’s their strength already. So that’s the market that this seems to be for. And yeah, I do agree with the small vessel sealer sizes is quite frustrating that any product that has the same size jaws as a regular cold Haney clamp does not fit through any of the ports for the V notes. And even though these tiny vessel sealer devices that we use for V notes they’re the same ones that we would use for an abdominal TLH straight stick at least they’re small. You have to basically take twice as long or more to secure the vessels than you would if you just did it vaginally with a larger vessel sealing device. So okay, so despite all of those objections, would you at least say that maybe doing a V notes vaginal hysterectomy, wouldn’t you say that is preferable to either an abdominal laparoscopic hysterectomy or even a robotic hysterectomy?

Howard: 56:07

Yeah, maybe. Maybe it does encourage people to get back down to the vagina, where they’re supposed to be, and learn techniques like anterior colpotomy and other pelvic prolapse techniques that are needed. And maybe it’s a training wheel that eventually comes off, especially if people realize gosh, I have the anterior and posterior colpotomy and this uterus is practically falling out. Why don’t I just take the next two bites and be done, rather than spend thousands of dollars of equipment doing this? So maybe that happens. I don’t know, but it certainly isn’t less expensive and it may be useful for some of the harder cases. Maybe in that 15% that I still do vaginally without assistance, maybe that 15% becomes V-notes for other people. But I’m not sold.

Antonia: 56:50

Yeah, I’ll say that I’ve had some cases where I asked to have it in the room and I thought I was going to do V-notes and then I actually just I got through everything and was like, oh, never mind, we just did a vaginal hysterectomy instead. So so maybe having it as an option can be for some people a bridge to just increasing their straight TVH numbers. So okay, so we’ve gone on quite a while. I think there’s some more specifics I want to get into that we’ll table for the next episode, because you were still going to talk about the Taj Mahal.

Howard: 57:22

Yeah, is that right? Yeah, have you ever been there? No, but my medical student has, and we were talking about it the other day and she described it as majestical.

Antonia: 57:32

Majestical.

Howard: 57:32

That’s the word she used.

Antonia: 57:34

Are we sure that that’s a real word?

Howard: 57:36

It is a word. I looked it up.

Antonia: 57:38

Okay.

Howard: 57:38

It’s in the Oxford English Dictionary. It was first used by a playwright named John Lyley in 1578, which means that it existed before the Taj Mahal, which was built between 1631 and 1653. My student also said it was very white and she remembers going there as a little girl and they took away everybody’s writing instruments so that she couldn’t graffiti the walls. But she said it was impressive and 10 out of 10 recommended a trip there sometime in your lifetime.

Antonia: 58:04

Okay, well, I have not been there either. So what’s our historical tidbit about it and why are we talking about it on this podcast?

Howard: 58:12

Well, I think most people in the world have seen, certainly, pictures of the Taj Mahal and know that it exists and that it’s a notable place to visit, one of the wonders of the world, but they may not realize what it is.

Howard: 58:23

It’s a tomb, right Right exactly, and I think many people don’t realize that. So it is the tomb of a woman named Luntas Mahal. It’s actually not a real name, but it was her name she was given. It was built after her death in 1631 by her husband, shah Jahan. Now Shah Jahan at the time was the Mughal emperor, and the Mughal empire in the 16th century extended into the Indian subcontinent. It also included much of Pakistan, Afghanistan and Bangladesh. Now, Mumtaz Mahal herself was of Persian descent and her father had moved to India in 1577, so she was born in Agra.

Antonia: 58:58

So she could be related to Freddie Mercury.

Howard: 59:01

You definitely know your British pop stars don’t you. Yeah, well, technically, Freddie Mercury was born in Zanzibar, which is in Africa, but yes, his family were also Persians living in India, though they were from the western part of India, Gujarat, but Agra is a little further north and more central. But, yes, both were descended from Persians who had migrated into the Indian subcontinent, and that makes Freddie Mercury the most successful Asian rock and roll artist of all time.

Antonia: 59:27

Okay. Well, do you want to get back to the Taj Mahal historical tidbit yet? Yes, ma’am, okay.

Howard: 59:32

So Mumtaz Mahal got married when she was 19 and her husband was 20. And this was in 1612, in Agra. And she went on to have a whole bunch of kids. So by 1631, she was pregnant with her 14th child. This was a prolonged labor that lasted about 30 hours, and after she delivered she developed a postpartum hemorrhage and she died, and her husband was away fighting a war.

Antonia: 59:54

At the time she was 37 years old, and so she had had 14 children in 18 years and about six weeks after her death her husband commissioned construction of the Taj Mahal as a memorial and a mausoleum for his wife. Well, who knew, the Taj Mahal is a monument to maternal mortality. So I guess that story just goes to show there is no patient who is truly without risk during pregnancy or especially childbirth. She had 13 uncomplicated, probably home births, but then she died in her 14th one. And well, her risk factor probably was her grand multiparity. But today, with modern obstetric care, especially in the hospital setting, she would have almost certainly been easily treated with and the hemorrhage itself would have been prevented by prophylactic administration of postpartum Pitocin. But if that didn’t work she could have gotten some extra uterotonics or maybe even a surgery, just any kind of standard basic algorithm to prevent that death.

Howard: 1:00:58

Yeah, right, so this is from a chapter in the new book I’m writing to illustrate that point exactly. I’ll also say that the technology that we have available and the medicine that we have here in the United States and other economically advanced countries in the world is still not available throughout the world. So India today still has one of the highest rates of preventable maternal mortality, and the leading cause of maternal mortality in India and in much of the African, sub-Saharan Africa and other similar low economically developed countries is still postpartum hemorrhage.

Antonia: 1:01:29

I’m almost afraid to ask, but did all of her 14 children survive?

Howard: 1:01:33

Well, that’s the other aspect of having children in that era without modern technologies, vaccinations, medical interventions, things like that. So her first child died at the age of three, and then later another child died at the age of three, and then she had one die at age seven. She had one die during birth and another died at age two and another one at age one and another as an infant. So out of 14 children, only seven live past the age of seven years old, and that was pretty typical for that century.

Antonia: 1:02:02

Just tragic all around. I guess, if I ever go see that Taj Mahal now, I’m just going to be really sad thinking about all of that. Anyway, that was a good historical tidbit, if a very sad one. But we should wrap up for today. So the Thinking About OBGYN website will contain links and also a video clip to things we talked about today, and we’ll be back to finish this topic up in a couple of weeks.

Announcer: 1:02:31

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