Episode 8.3 Antiquated Physical Exam Techniques, Cord Blood Banking, and More!
In this episode, we challenge the reliability of traditional tests like Homan’s sign and cervical motion tenderness. Learn how understanding and applying likelihood ratios can vastly improve diagnostic accuracy, and why combining multiple findings is more reliable than putting faith in isolated tests
Then we discuss a new JAMA study linking advanced endometriosis with a heightened risk of ovarian cancer. The study brings to light the complexities and gaps in our knowledge, underscoring the importance of personalized patient discussions regarding risks and treatment options.
Next, we discuss a new study about how surgical residents are treated during pregnancy. From inadequate parental leave to cultural pressures, we highlight the urgent need for systematic changes to foster a supportive and equitable environment.
Then expose the deceptive practices in the umbilical cord blood banking industry, revealing the ethical issues and questioning the touted benefits.
Finally, we answer listener questions about use of sterile gloves for cervical exams and trials of labor after two cesareans.
00:00:02 Obsolete Physical Exam Maneuvers in Gynecology
00:14:25 Endometriosis and Ovarian Cancer Risk
00:20:47 Residency Challenges for Parents and Discrimination
00:33:10 Deceptive Practices in Cord Blood Banking
00:49:19 Debate on Mammography Guidelines
00:54:17 Listener Questions: Sterile Gloves and VBA2C
Links Discussed
Evaluation of Acute Pelvic Pain in Women
Accuracy of five different diagnostic techniques in mild-to-moderate pelvic inflammatory disease
Usefulness of bowel sound auscultation: a prospective evaluation
Endometriosis Typology and Ovarian Cancer Risk
New Insights in Endometriosis Subtypes and Ovarian Cancer Risk
Pregnancy and Parenthood Among US Surgical Residents
Promised Cures, Tainted Cells: How Cord Blood Banks Mislead Parents
Transcript
Announcer: 0:02
This is Thinking About OB-GYN with your hosts Antonia Roberts and Howard Herrell.
Howard: 0:17
Antonia Howard. What are we thinking about on today’s episode?
Antonia: 0:21
Well, even though we just did a bunch of fresh articles last time, we’re going to do some more fresh articles because there’s just some really good ones out there and we’ve also got a couple of listener questions we’ll hit. But first, what’s the thing we do without evidence?
Howard: 0:34
Well, how about performing unreliable physical exam tests like Holman’s, for example?
Antonia: 0:40
Okay, sure, I’m sure there’s going to be lots of eponyms again here. So the HOMEN sign is when you force dorsiflexion of the foot while the knee is straight and in theory, if that causes discomfort up the back of the leg, it’s supposed to be a sign of DVT, dvt will have a positive Hohmann sign, and nearly half of patients who have a positive Hohmann sign, well, they don’t have a DVT.
Howard: 1:11
So this makes this test neither sensitive nor specific, and the danger of a sign like this is that it somehow changes your management or your diagnostic workup, with a result from a test that performs that poorly. You shouldn’t do anything different from what you were going to do before you did the test, regardless if it’s positive or negative. So if the patient needs a D-dimer or an ultrasound or whatever would be appropriate, then that test shouldn’t change the necessity of that, and if they don’t need it again, it shouldn’t change that either and all of a sudden make them need one because they have a positive test.
Antonia: 1:38
I’m sure these were all born out of a time before there was lots more specific tests, and I like to think of these kinds of physical exam maneuvers as what we would do if we again had no technology, like maybe if we were in a jungle or, let’s say, we were on a cruise ship or just somewhere else remote where we couldn’t check a D-dimer or do a CT scan. But even then, even on a desert island, it might still lead to worse decisions than not doing those maneuvers at all, since they’re so poorly predictive of the diagnosis. So if it doesn’t change the management and if it wouldn’t even be useful on a desert island, then we really shouldn’t do the test and in fact someone might be falsely reassured by the absence of a home and sign and not pursue a workup that they would have been able to pursue and should have pursued, and then that would be one way that this leads to patient harm.
Howard: 2:34
Right. Or the opposite may occur too, where an unnecessary workup takes place because this test is given too much value or more value than it should be, particularly if it’s used in a patient who starts out with a low pretest probability of thromboembolism.
Antonia: 2:47
Okay. Well, what other physical exam maneuvers would you classify, along with the Holman sign, as being? I guess we’re saying these are worse than useless.
Howard: 2:56
Well, I’m sure there’s a bunch, and readers should tag us on Instagram if they think of some that we don’t talk about, but, just, for example, ones that our audience may care about. How about a cervical motion tenderness exam for pelvic inflammatory disease?
Antonia: 3:10
Okay, yeah, and that is a cornerstone of medical school teaching, or at least it was when I went through.
Howard: 3:16
So tell us more about this one and why it’s so bad yeah, the chandelier sign or whatever, but essentially this is the Hohmann sign of gynecology. So the positive likelihood ratio of finding cervical motion tenderness is only 1.1 and the negative likelihood ratio is only 0.9. The same actually is true for just pelvic tenderness, which has a positive likelihood ratio of 1.0 and a negative likelihood ratio of 1.0.
Antonia: 3:45
And why don’t you just explain again real quick to the listeners what the likelihood ratios are? What do these numbers mean?
Howard: 3:52
Sure Well. So likelihood ratios are multiplied times the pre-exam odds of having whatever disease you’re worried about. So if the test is positive, then you use the positive likelihood ratio and if it’s negative you use the negative likelihood ratio. So if you thought that the odds of someone having pelvic inflammatory disease was, say, one to 10, and these are odds, not probabilities, before you examine them then finding or not finding pelvic tenderness wouldn’t change those odds at all. And if you found cervical motion tenderness, well then, if it was present, it would be 1.1 to 10 multiplied the one times the odds, the likelihood ratio, and if you didn’t find it, it would be 0.9 to 10. And those ratios are not materially different. Again, they wouldn’t change your management. The sensitivity of cervical motion tenderness for PID is only 63% and the specificity only 40% for pelvic inflammatory disease in a population of people who have an intermediate risk.
Antonia: 4:50
So would you say that these tests are completely worthless altogether the cervical motion tenderness and pelvic tenderness or just worthless as standalone decision points for managing these patients?
Howard: 5:05
Well, much like we do with tests for ruptured membranes, which we probably could dive into that on some episode, you can combine several exam findings or history items or things like that together to come up with an aggregate assessment that is sensitive and specific. But that would mean finding adnexal tenderness, which is very sensitive, along with purulent cervical secretion, which is very specific, both about 93%, as well as things like an elevated white blood cell count and fever. But the mistake is thinking that just because someone has cervical motion tenderness or even adnexal tenderness, that they have pelvic inflammatory disease and in many cases the test isn’t worth doing because the rest of the clinical picture is so suggestive for or against PID that the test doesn’t add anything to that decision calculus. This is especially true today, when these patients have often already had or will be getting a pelvic ultrasound.
Howard: 6:00
And many of them when they’re evaluated through the emergency department. They’ve already received pain medication, which further complicates the interpretation of physical exam, but also the imaging. Well, it may make the exam completely unnecessary.
Antonia: 6:12
All right, and I’m thinking of lots of other older physical exam signs that we really don’t use in daily practice but that medical students are often pimped on daily practice. But that medical students are often pimped on or it seems like at least these terms continue to hang around and review textbooks. So I’m thinking of things like the Chadwick sign, which is bluish discoloration of the cervix or vagina that is supposed to appear in early pregnancy and be a sign that this patient is pregnant. Or the Goodell sign, I think is how it’s pronounced, and that’s the softening of the cervix that occurs during pregnancy. Or the Ossiander’s sign, which is a pulsation that you can feel through the lateral vaginal fornix, and it’s another sign of pregnancy, presumably because the uterine arteries have become larger and they’re perfusing the uterus and the fetus.
Antonia: 7:11
And then there’s the I might butcher this the piece check sign, which is just an asymmetry of an enlarged, palpable uterus during pelvic exam. That also indicates pregnancy, although obviously that wouldn’t rule out a big fibroid uterus or cancer, for example. Then there’s the polymer sign, where you can feel uterine contractions during bimanual exam. There’s the Hagar sign that occurs when you can spread two fingers in the anterior fornix and then feel the softening of the lower uterine segment. All of these are just signs of pregnancy and I’m sure I’m missing a bunch there.
Howard: 7:43
Yeah, it’s crazy. And it’s crazy too that students are often encouraged to still learn like Chadwick and Hagar, as if they’re important to our clinical practice. And there’s a Jacquemere sign, which is just erythema of the vestibule and vagina, and the Von Braun Fernwald sign, which is irregular softening and enlargement of the uterus during pregnancy, and just a bunch of other things named after different people all men probably.
Howard: 8:08
And they’re all really the same thing and all of these are really important. Maybe 100 years ago, maybe even 50 years ago, when we were seeing patients and trying to understand, without labs or ultrasound or Doppler or anything else, if she was pregnant, and we combined all of these really low quality, low sensitivity, low specificity signs along with our clinical history and tried to come up with an idea about whether she was pregnant and maybe how far along she might be. But we replaced all of these with a simple urine pregnancy test and so therefore, these are of historic interest only, and no one would actually ever manage a patient using these signs and symptoms in today’s world.
Antonia: 8:47
Yeah, we really don’t even think about these signs, not even for a millisecond, let alone look for them. And this is to the patient’s benefit, because they do not need to undress and put their legs in stirrups to confirm whether they’re pregnant or not. They don’t even need to see a provider. They just need to leave us a urine sample or maybe a blood sample, maybe tell us some history like when was their last period, that kind of thing. Are they nauseous? They might get an abdominal ultrasound if the timing is right. So getting back to the cervical motion tenderness, it’s not really the way we would manage a patient anymore, because we have better tests and so performing that test is mainly a relic of academic interest. Can you think of any other physical exam findings that we do? That are worthless.
Howard: 9:37
But before we move on to our main topics, Well, just to make sure that we get lots of emails from angry folks. Oh gosh, how about?
Antonia: 9:44
aus. We get lots of emails from angry folks. Oh gosh.
Howard: 9:46
How about auscultation of bowel sounds?
Antonia: 9:49
Okay, well, that’s a good one, especially for us.
Howard: 9:52
Well, in theory, bowel sounds help you evaluate a patient who may have a small bowel obstruction or a postoperative ileus, but in practice, these bowel sounds just have no diagnostic clinical utility at all. These bowel sounds just have no diagnostic clinical utility at all and they often again may mislead clinicians into making the wrong diagnosis and therefore they’re just not useful clinically. I’ll put a link to a 2014 study which makes that point in a more full way.
Antonia: 10:15
Yeah, definitely In my surgery rotations I would have patients that weren’t allowed to eat for days and days and days until they had positive bowel sounds after surgery, for days and days and days until they had positive bowel sounds after surgery. But then I also had an OBGYN attending who routinely would make me listen to bowel sounds on rounds and would stop me, would not let me continue until I had listened to all four quadrants with my stethoscope.
Howard: 10:38
Yeah, well, and that was for routine postpartum patients after a vaginal delivery. That’s right, and you’re supposed to listen for 30 minutes in each four. So did you listen? If you didn’t hear them, did you listen for two hours?
Antonia: 10:50
I guess we didn’t even do that part right exactly. It was like listen for five seconds, five seconds, et cetera, and that particular person taught a lot of other, I think questionable things as well, like prescribing ovulation induction meds and normal, healthy patients that just wanted to conceive more quickly.
Howard: 11:10
Yeah, Well and honestly. This is why we do the podcast. We’re trying to set the record straight for everyone who’s heard these wrong things, both from outside and especially inside our profession. And there’s culturally. We could do a whole episode of just a list of a hundred things. One that comes to mind could be pre-albumin as a sign of whether the patient is under earned or nourished. It’s not a thing. It’s not a thing If your attending is telling you that they should read their textbook. There’s a bunch of things like this. Or how much urine output is adequate per hour. Everybody has 30 mls per hour in their head and that’s not actually based on renal physiology. It’s not the same for a 20-year-old, 200-pound male as a 73-year-old, 110-pound woman with decreased glomerular filtration rate. We have so many of these cultural things that there’s dozens of them.
Antonia: 11:58
Yeah, and I guess at this point I’ve probably taught enough that maybe some of these have come through me as well. So if someone out there is just fuming because I taught them something really wrong or stupid, then call me out on it, let us know. I’ve, you know, I’ve hopefully improved from whatever that was, but you know, sometimes getting this kind of feedback is good, so I would welcome it.
Howard: 12:24
Right. So many things are just traditional and they’re taught at the bedside from generation to generation and there’s very little critical analysis.
Howard: 12:31
That goes on. Many of them are carried over from a day and age in which they might have had some utility in absence of more modern tests or just these practices hadn’t been studied. Being NPO for acute pancreatitis, for example, probably happens in every hospital in America. It’s not evidence-based, it’s not necessary and there may have been more nuance to some of these tests or these things than how they’re currently taught. Maybe people did physical exam better back in the day. That’s an argument obviously.
Howard: 12:59
But I guarantee you that no ER doctor out there today can actually tell the difference between pelvic floor myalgia and cervical motion tenderness. Why would they? They don’t actually have to rely on that exam finding at all. So just as the pregnancy test has superseded all of those physical signs of pregnancy that you listed well, so too the ultrasound of the lower extremity has replaced the Holman sign, an ultrasound of the pelvis has replaced the chandelier or cervical motion tenderness sign, and a simple x-ray has replaced auscultation of bowel sounds.
Antonia: 13:30
Yeah, I like to think about why was it ever even called the chandelier sign? Was this from a time where they had chandeliers in hospitals? Or from concierge physicians visiting people examining them under the chandeliers of their main room, or something?
Howard: 13:47
So I think it’s supposed to be because they ran up the bed when you touched them, but maybe there’s a history buff out there that can tell us.
Howard: 13:53
But yeah, well, anyway, well we might make the same point about the measurement of fundal heights, which we’ve talked about before, and lots of other things which have a historical legacy. It was the best we could do with something 50 years ago or a hundred, but it turns out no scientific validity for modern practice. And that doesn’t mean that there aren’t some physical exam findings which are very useful. But it’s our job to know these positive and negative likelihood ratios of whatever test we’re doing and use them for the given conditions that we’re concerned about, and use tests when they’re appropriate and don’t use them when they’re not appropriate.
Antonia: 14:25
All right. Well, let’s move on to some more fresh articles again. So there’s a study in the July 17th 2024 JAMA called endometriosis typology and ovarian cancer risk. This study found that women with endometriosis are more than four times more likely to develop ovarian cancer than those who don’t have endometriosis, and for women with endometriomas or other deep infiltrating stage four type endometriosis, they’re almost 10 times more likely to get ovarian cancer compared to baseline. And when they do, those cancers are more likely to be the endometrioid or a clear cell or a mucinous or low-grade serous types compared to the other what I’ve heard described as garden variety high-grade serous ovarian cancers.
Howard: 15:21
Don’t say that to a woman who has one. Well, no, yeah, this is probably the best study that we have to look at the magnitude of this risk. This risk association is something we already knew, I think, but until now it was based on lower quality data that use often self-reported diagnoses for endometriosis, which can be very inaccurate. In contrast, this study used a confirmed diagnosis by a medical provider, and this study confirms the findings of a previous study that relied heavily on Finnish and Swedish data, but of course, we know how good Finnish data is at least I don’t know about the Swedes.
Antonia: 15:55
I’m sure the Swedes are pretty good too. But yeah, of course I’m biased about Finland being so great with women’s health data and practice and everything, so maybe someday I’ll make just a Finland only or maybe a Nordic only episode for this podcast, highlighting everything that they’ve done for OBGYN, but not today.
Howard: 16:17
Maybe that can be our next Finnish Independence Day special, or we can do it in two years during the Winter Olympics, when they’ll do a little better than they do in the Summer Olympics.
Antonia: 16:27
Yeah, they almost have the record for lowest amount of Olympic medals ever.
Howard: 16:33
Well, the database in this paper had more deep infiltrating cases as well, which the previous study did not, so it adds a lot to our understanding.
Howard: 16:40
It’s all very interesting really when you consider how much potential risk we’re talking about.
Howard: 16:45
So the next question will be should women who have stage three or stage four endometriosis the ones with the higher risk, deep infiltrating for example, things like that should they have risk reducing surgery when they’re done with fertility? It doesn’t quite bring them up to the level of being BRCA positive, but in that population of course we do recommend risk-reducing oophorectomies, but it’s still much higher than the general population and of course we don’t have good screening for ovarian cancer. And also, how helpful is it for this population to be maybe on suppressive birth control pills, something that we might do with a younger patient who is BRCA positive? So we know it reduces the risk of ovarian cancer, especially compared to other potential treatments for endometriosis or even surgical excision. It seems that suppression with birth control pills could reduce the cancer risk for patients like this and many of these women with the most advanced forms of endometriosis probably would benefit from risk-reducing surgery and maybe just from their symptoms of endometriosis, let alone risk reduction when they’re, of course, done with fertility, since they have that higher cancer risk.
Antonia: 17:52
And there is an accompanying editorial that we’ll link to showing some of the knowledge gaps we still have and how difficult it is to come up with any specific recommendations for any one patient, let alone a whole category of patients. We still don’t quite understand how endometriosis can or does undergo malignant transformation into cancer, but there are some multifactorial theories. There’s also a problem of accurately defining what is deep infiltrating endometriosis, and the data doesn’t address confounders like gene status or family history. So what if there’s someone that’s BRCA positive and they have endometriomas? Would they be compounded extra high risk or just still the same level of risk? But the editorial does conclude that women with more advanced endometriosis should at least have a detailed discussion about definitive surgery, which would include oophorectomy, once they’re done with childbearing, given this increased risk.
Howard: 18:57
Yeah, and I probably haven’t included this part of that in that conversation we don’t have good screening tests for ovarian cancer and until we do like we do for BRCA positive women for breast, well then enhanced screening isn’t necessarily going to be an option for this cancer. If a person knew that she had up to an 8% risk in her lifetime the stage threes and fours of developing ovarian cancer, plus symptoms of endometriosis and things like that, I think many of them would undergo risk-reducing surgery.
Antonia: 19:29
Yeah, I think so too. I have plenty of patients at average risk who still want their ovaries out, which we can reasonably do opportunistically after age 50, but there are still some drawbacks to losing their ovaries even that late in life, let alone when they’re premenopausal.
Howard: 19:48
Right, we talked about prior to this season. We talked about that study that discussed whether to opportunistically remove the ovaries during hysterectomy, and nothing’s without risk, obviously, but the overall risk of removing the ovaries in the general population seems to balance out at around age 50. Remember, if you can add estrogen back which might not be the case for a particular patient, and it’s definitely advantageous after around 65, regardless of whether or not they take estrogen. So in this subpopulation of endometriosis patients, many of them could easily benefit from hysterectomy due to their symptoms. So a simple way to think about it is that if their ages for when to offer and when to strongly recommend nephrectomy are going to be shifted a little bit earlier than in the general population because of their enhanced risk of cancer we can’t firmly say, though, for a given patient, exactly what those ages are. We should still involve patients in informed decision-making about that and let them know what the areas of uncertainty are.
Antonia: 20:45
Yeah, Well, let’s move on to another article. So in that same edition of JAMA there is an article focusing on pregnancy and parenthood among US surgical residents and to no surprise at all, they found that female residents who had children during residency experienced more mistreatment than their male counterparts who also had children. Residency experienced more mistreatment than their male counterparts who also had children, and they had more postpartum depression along with more burnout and more thoughts of quitting residency.
Howard: 21:13
You mean to tell me that surgeons treat female trainees poorly during their surgical residency, especially if they take time off to start a family. I’m absolutely shocked.
Antonia: 21:20
Of course you’re not, but obviously this is a continuing problem where probably most surgical fields, including OBGYN, still are not very family-friendly, so I’m sure this is not limited to general surgery for what? This study just used general surgery as one example. Obviously, we would like to think that in OBGYN we do a better job of this, because this is what we do we bring babies into the world. But, as we talked about a few episodes ago, there is still an incredible amount of mistreatment in our specialty’s residency programs as well, and the authors of this article naturally conclude that systematic changes are needed to prevent this mistreatment and prevent attrition related to gender and gender-specific causes of burnout.
Howard: 22:10
Or even just female students choosing a residency program like this to begin with. Choosing a residency program like this to begin with. So a quarter of the female residents who were surveyed in this study were told that they should not have children during residency by somebody in the program, but only 3% of the males were told the same thing. And 40% of the females were told that they should consider an easier specialty if they wanted to be a parent, which again was twice the rate of male residents being told that. Four times as many women, compared to men, reported negative reactions from their co-residents or their attendings if they took time to tend to their pregnancy or child care needs, and the average male took two weeks or less of parental leave, whereas the average female still only took three to six weeks. And if you think about that for a minute, a lot of them are only taking three weeks after they gave birth and then going back to working 80 hours a week.
Antonia: 23:01
And I’m sure they were probably still getting calls or emails or something pressured to do some work while they’re breastfeeding during that first three weeks and grief from their co-residents for having to pick up some slack. Yeah Well, I’m not sure how we fix all of these problems. We’re so good at fixing things on this podcast, don’t?
Howard: 23:20
you think?
Antonia: 23:21
But it is a complicated problem and, just as we discussed with bullying and mistreatment on the episode previously, this frankly starts with the attendings and the program leadership.
Antonia: 23:33
They really should be ashamed of themselves for telling residents of any gender to consider an easier specialty or to not have kids at all, as if being a surgeon means you are a child-free person, you’re committed to surgery and nothing else. It’s like they forget that we’re all human beings. We’re going into this field to help human beings and we are human beings ourselves. We all have personal lives and it’s up to the department chairs and faculty and program directors and all those people to be leaders and support their colleagues, including their colleagues in training, with whatever work life balance they’re engaging in that they need in a fair and equitable and reasonable way. And sometimes I wonder if some of this negativity doesn’t come from people in the field who are child-free or single, kind of saying like why should you get more time off than me just because you got pregnant, I don’t get the same time off? It’s not fair. I’ve actually heard that. I’ve heard that. I’m not just making that up. I have too heard that I’ve heard that.
Howard: 24:35
I’m not just making that up, I have too definitely.
Antonia: 24:37
Yeah, it just has this flavor of bitterness, so I don’t know. Maybe one idea would be give everyone the same amount of time off, child-free people with kids, give them that same amount of time. Just because people don’t have kids doesn’t mean they don’t deserve some decent time away from work, and then maybe they wouldn’t be so bitter about other people getting the same time away from the hospital.
Howard: 24:58
Well, and of course male residents never take the time.
Howard: 25:01
anyway, the father’s a potential person who didn’t actually give birth is often takes no time off right, because of that same cultural pressure, and maybe some people would happily take those extra weeks off. Maybe some would rather opt not to lose out on getting to do certain surgeries or just not having any gaps their training, so they could opt out of that time anyway. I will say in Europe, you know, it’s an expectation that people have a certain number of weeks of vacation and it doesn’t financially harm them and it’s a totally different culture in the United States.
Antonia: 25:30
Yeah, so actually that time away from training to tend to a newborn, just taking that time away, can actually be a burden rather than a relief, because then you do miss out on more training and have to make up stuff on the tail end. So not necessarily something to be jealous about, but on top of that, obviously it’s not like that time away from the hospital is spent just hanging out in a spa, sleeping nine hours every night, catching up on all the best TV shows and that kind of stuff, because recovering even from a completely, perfectly smooth childbirth is still like getting hit by a bus. And then, even if someone did that, push their baby out quickly, zero complications, and then was able to get eight hours of sleep every night immediately. Still, I’d say six weeks off for just the recovery should be a minimum, just for that. But that doesn’t happen.
Antonia: 26:29
People don’t sleep eight hours a night after having a baby because there’s a baby. Even a healthy baby is very needy. They’re going to be up every couple hours or so. They need to be eat and changed and constantly held and all of that stuff Constantly watched so that they’re still breathing and getting cleaned when they spit up, and just everything. And then if you have other kids who are awake during the day, they’re not going to let you sleep during the day. They need attention too. So that time away from work after having a baby can quickly become one of the most exhausting experiences anyone has ever had. So anyone out there who wants to call this parental leave a vacation, I don’t know what to say. They deserve to just go constantly, change diapers every day and only get 90 minutes of sleep every day, have their nipples burning and maybe have their pelvic floor just completely give out as if it’s not even there and then go back to work three weeks later.
Howard: 27:26
That sounds like some sort of medieval curse, but yeah.
Antonia: 27:31
It’s a little fresh. I’m only seven months out, so yeah.
Howard: 27:35
And then when you do go back to work, then you are forced to make up the time that you missed, or it may even set you back from graduating and you graduate off cycle because you had a couple of babies. It’s not the same as in that regard either.
Antonia: 27:47
Yeah, and you go back to work and it’s not like it’s all over and now someone else is constantly taking care of the kids. Especially if you’re trying to breastfeed and pump milk, then that’s a whole new added burden. Once you’ve returned to work, you have to clean everything, store everything, and then you still have to be blissfully happy because you have a living child and you have this dream job right. So think about if anyone goes through the childbirth and they’re healing from all that physically and then they don’t have a healthy child or a living child, then I would say don’t ever anyone out there even think of suggesting that they go back to work until they’re ready.
Howard: 28:26
It does take a lot of sacrifice to grow a family and have children, and while I do get the argument of letting the child-free surgeons take the same amount of time off so that they wouldn’t be bitter without having to work more, their time off actually would actually be a vacation compared to what you just described. Parental leave is arguably doing one of the most important jobs that exists, which is keeping this new baby alive and well, and this baby needs its parents. Most daycares won’t start even taking kids until they’re six weeks old. If you can get into a daycare or afford it, and most live-in nannies are just way too expensive to even consider, even for well, especially for residents, but even for doctors. So a job that’s intensive. There’s really no other option but to have parental leave. So it’s how we’re culturally treating it. That’s the problem.
Antonia: 29:11
Yeah, and the recovery. It’s not like you would send someone back to work after three weeks after major abdominal surgery. So it is a major physical change to recover from. So it’s at a minimum, a medical recovery. But I think we all understand most of the parental leave is really directed towards the child needs, not the parental medical recovery from it.
Howard: 29:34
What they should be doing at residency programs because most people in residency happen to be in their peak childbearing years is encouraging people to take a couple months off and letting them know that it’s wonderful and take whatever time they need, and designing programs that have flexible scheduling and optionality built into them so that people can tend to their personal lives, whether that’s related to pregnancy or anything else. It’s almost impossible when you’re a resident or at least when I was a resident to even go to a doctor’s appointment or go to the bank or pick up your dry cleaning, let alone perhaps have a weekly appointment with a therapist or go to regular prenatal visits or anything like that, and all that has to change and it has to feel like more of a regular job that syncs and meshes with your life.
Antonia: 30:17
Yeah it. I think it is a regular job, but it’s all part of this kind of rite of passage. I think there’s this silly idea that in residency your colleagues and your team will be punished for you not being there to tend to your life, because they’ll have to cover all of your call shifts or whatever else you were normally tasked with. It’ll just be added onto their workload and that would just be totally unacceptable. So you can’t even take time away for the dentist twice a year, let alone to have a baby. So I delayed having kids in residency because I felt like I couldn’t handle that responsibility on top of my training. But I think if I could go back and talk to my residency self, I would basically say nobody really needs you.
Antonia: 31:02
You’re a resident. There’s multiple layers of doctors above and below who are here. They can absorb what is actually a pretty minimal patient load, even though it didn’t feel minimal to me at the time. Everyone will be fine. Keep the dental appointments, sleep for more than five or six hours a night, get a little bit of exercise and go ahead and do the fertility treatments if you need them, or plan for a kid. This is probably the best time to do it, and everyone in the hospital will be fine if you draw some boundaries and just take care of yourself a little bit more.
Antonia: 31:35
It’s really not a huge inconvenience for anybody If you leave for an hour or two once a week to go to a prenatal appointment or some other kind of appointment, or maybe sometimes leave early to pick up a kid at daycare, and really other people should be happy to help in those circumstances, just like you would help them. None of this changes until people stop these cycles of abuse and shame for trying to be a normal person. So if anyone out there listening has ever told a female doctor or resident not to have a baby or even thought in their minds that you shouldn’t be having babies, if you’re trying to be a surgeon or be a resident, then I would invite you to come on this podcast and let us interview you. I think it would be a good conversation, if maybe a short conversation We’ll see, sassy, aren’t you?
Antonia: 32:25
I mean, someone has to be.
Howard: 32:27
I had two more thoughts too. This also, of course, contributes to the wage gap, especially in professional women’s careers, because they do take time off and have discontinuity of their careers and are punished for that, and so that’s a large part of the wage gap that exists in professional women’s salaries or academic. The other thing, the other thought I had, is an attending should be able to do the whole job without residents. If you’re in a situation where the attending actually needs residents to get the work done, you’ve got unsafe supervision ratios.
Howard: 32:58
So, yeah, what was a big deal for you as an intern and what you might have spent three or four hours doing as an intern. Let’s be honest, I do in 10 minutes and the attending should be able to step up and deal with a resident not being at work, but anyway, ok, I know we’ve discussed umbilical cord banking in the past, but there’s a New York Times article that I thought was wonderful from July 15th and it makes many of the points that, frankly, I’ve been discussing about umbilical cord banking for years. The authors talk to around 60 physicians and sales reps and other people in the industry and we can put a link to that article if you have a subscription to the Times. But it’s well worth looking at.
Howard: 33:40
I’ve been dismissive of umbilical cord banking since I first heard about it many years ago and researched it. I actually remember back in the mid-2000s sort of investigating the companies who were selling these products and trying to understand their industry, and one of the things I did this is the kind of stuff I do I looked at their corporate financial filings with the SEC, tried to understand how they sold things and their advertising campaigns and looked at the evidence for it, and I recall that almost all their advertising dollars back then went to subsidizing many of the early pregnancy chat rooms or sort of mommy community websites, like dozens of them, ones that are still around. They own them and when you went to those various websites, it wasn’t obvious to the people making accounts and joining these communities that they were in fact owned and paid for by companies. But when you looked inside the chat rooms, you would frequently see some person recommending it or talking about it, and it was pretty clear, if you knew what was going on, that this was just deceptive and dishonest advertising.
Antonia: 34:41
Isn’t that called social engineering? It sounds pretty similar. Yeah Well, it’s very sneaky. It’s because the product doesn’t actually have the kind of true success that would speak for itself If it did have any promise at any point in the past. It really doesn’t have that now because they’re not even using these cord blood stem cells in most of the research now, let alone treatments. They’re able to use stem cells from adults, doing a blood draw on an adult to achieve the very same thing that you would with cord blood, but with a better yield.
Antonia: 35:19
So one of the problems with cord blood banking is that there are usually very few usable, viable cells recovered from the samples, and also many of the samples that are sent in and stored will still get contaminated with microbes, so it makes them unsafe to use.
Antonia: 35:36
And one of the scandalous points of this New York Times article is that in a lot of cases the storage companies would be aware of these facts when they tested the samples, but they would never notify the family and instead they would just keep charging hundreds and hundreds in storage fees for years and years until they got unlucky enough to where a family would say, hey, I want to use my cord blood for this and then they would be told oh, it’s actually contaminated, but thanks for the money. But these companies have used celebrities like Drew Barrymore or Chrissy Teigen to sell what is essentially a very extreme and fringe insurance policy to parents. They partner oftentimes with hospitals and hospital systems and in some cases will provide kickbacks to the doctors and just lots of other kind of unethical and shady promotional methods to convince parents that they should invest in cord blood banking. And their selling point is just in case, let’s say, one of your children develops a rare disorder that they could die from, unless you use this frozen cord blood, that’ll save their life.
Howard: 36:47
Yeah, and I’ve maintained that to this day. We really can’t point to a single child who’s ever actually benefited from cord blood banking after decades of this practice. The article does say that there have been just 19 stem cell transplants from a child’s own cord blood since 2010. But even that doesn’t mean that any of those children benefited from getting the transfusion. In many cases, the transfusion was given along with the conventional or traditional treatment for whatever disease, and so there’s no actual evidence that the children benefited from the transfusion. They just received it.
Howard: 37:20
And yet these companies have paid some obstetricians, as you said, up to $700 for each patient that they recruit to give a sample. This sort of stuff happens more than you think. They may call it a collection fee or a counseling fee or something like that. Some of the companies that sell non-invasive prenatal screenings using cell-free DNA technology they do the same thing. They’ll pay several hundred dollar fee to a maternal fetal medicine doctor for acting as their genetics counselor when they recommend the test to patients. I actually found this out by accident when I ordered a test one time from a specific company that I don’t normally use, because they tested for something I needed for a particular patient, and then, about three weeks later, I got an unsolicited check from them in the mail, and then I realized why the local MFM was always using that brand of test for every single patient because there was a kickback involved.
Antonia: 38:09
In case anyone’s wondering, I do not get kickbacks for anything I do.
Howard: 38:14
I don’t either, or any test I order, I don’t either.
Antonia: 38:16
Yeah, okay, just wanted to put that out there.
Antonia: 38:18
So back to this article.
Antonia: 38:20
They did mention that for certain things like leukemia which is probably what most patients are worried about their kids getting and dying from when they’re considering this product anyway you can’t even use that kid’s cord blood because those stem cells are also more likely to turn into that same cancer.
Antonia: 38:40
So it’s really limited what you could use a kid’s own cord blood for, and it’s not for the thing that people are probably most worried about. You would in that case have to use a different, healthy child’s cord blood on a kid that happens to match for the kid that has leukemia, so maybe a sibling, or maybe through an unrelated public banking system. So most patients probably don’t realize that point and I don’t think that’s very well advertised by these companies. But the three main companies that do this have sold the cord blood banking kits to about 2 million parents, and the biggest of the three companies, cbr, which is cord blood registry, is owned by Cooper Surgical, and you can read the article to learn more about the FDA investigations of their unsterile lab practices and just the individual experiences of parents who spent thousands of dollars storing their blood only to find out that it was unusable all along.
Howard: 39:42
Yeah, I recall, maybe 15 years ago, being told that realistically you didn’t see usable amounts of cells, even if they weren’t contaminated after about two or three years after initial freezing if you were to thaw it out. And this investigative report really paints that picture completely. And 20 years ago these companies were convincing many states to pass publicly funded banks, and more than two dozen states actually built up cord blood banks with tax dollars and they required by law that obstetricians tell patients about this option, even though the whole thing really was a scam from the beginning.
Antonia: 40:23
I don’t think everyone who went into the line of work was a con artist and maybe it did start out with some true hope. But since now there are other options out there, including the adult stem cell extraction that gives more usable stem cells, and of course there’s bone marrow transplants. That’s always been around, I would say after reading this article it would be hard to view cord blood banking as anything other than a dishonest scam with tons of ethical problems. If you’ve listened to our podcast long enough, you will know to have a natural distrust for big medical companies when they’re selling products. So on the one hand, cooper Surgical sells some very vital tools for women’s health and then, on the other hand, they also sell just scams like the fetal pillow and cord blood banking, along with their less than pristine sales practices for those products.
Howard: 41:17
Yeah, the message is always the same. You need to look at the evidence yourself and minimize your contact with industry if you don’t want to be biased by the sales pitch.
Antonia: 41:27
And in any case, where there is direct physician payments for using a product or recommending a product to a patient, I think we have ourselves really in a murky ethical space and that’s just simply hard to defend in most cases, they did review the evidence about a variety of diseases and test cases where umbilical cord blood cells have been used or could be used, and most of those diseases and cases have been either dead ends or, at a minimum, they would have had some other alternative treatment besides cord blood that would have worked equally well, if not better.
Antonia: 42:03
So if you’re recommending or have patients inquiring about, this is actually a decent review of the evidence about cord blood banking, so definitely read it. The Cooper Surgical Company bought CBR for $1.6 billion in 2021, just as they recently bought the company that sells the fetal pillow, for that one was for tens of millions of dollars, so of course, that means they’re going to get their money’s worth out of it. So you practitioners and patients really need to be leery about their intentions. You may actually, and probably will, be seeing more sales information and more aggressive rep activity out there about this. I think we’ve already had one rep come by our office really talking this up. Come by our office really talking this up. And even though the article paints a pretty good picture that at least most in the medical community have moved beyond this, the advertisements to patients, I think, are still fairly strong, like the activity on those mommy blogs is still just as active as ever.
Howard: 43:04
I’ve collected several of these over the years for patients who requested it and until reading this article I didn’t know that all three of the large banks will actually pay between $150 and $700 for collection fees.
Howard: 43:18
So they owe me some money. They also never paid me. They also interviewed a physician in Atlanta who essentially bragged about how it’s virtually no work at all for less than five minutes of your time and you make 200 bucks. But then he also said that he didn’t think that that money was enough to change how doctors behave. And maybe it isn’t for him, but if you deliver 100 babies a year and you tell your patients about this, that’s $20,000 extra. That’s vacation money, real good vacation money. We know from pharmaceutical sales literature that doctors will change their practices significantly just for a free lunch, let alone an extra $200 cash every time you deliver a baby disproportionate, because really it’s about 60 seconds of extra work and all the supplies come from the company, so it’s not like it’s costing you or your department or your labor ward any extra time or space or resources at all.
Antonia: 44:21
The companies will often also pay women a $25 gift card to come listen to their sales pitch, for which they will pay local labor and delivery nurses to lead those sales pitches. So you end up incentivizing the patients with this gift card and then using a trusted figure to scare them into going forth with the full package however many thousands that is and collecting and storing this blood. I’ve also done quite a few of these because at one point there was a state funded public cord blood banking program during my training. It really only lasted about a year, but for a time we were collecting cord blood for almost all patients. There was no extra payments involved and it was going to a public bank, and at the time it was thought that this could potentially help the public.
Howard: 45:11
Yeah, that was one of the other things. The article talked about how a public bank would really maybe be the best chance of anyone’s cord blood actually getting used, but even then, because of how rarely it’s needed, the whole thing crumbles under the costs, which these companies also benefit, of course, because they contract to run these for the state. I’ll reiterate here that there are currently no conditions that we know of for which cord blood is the only life-saving treatment. So anyway, it’s reverted back to private banking only in most cases, I think and they fund the cost by massively charging these patients.
Howard: 45:43
One of the things that Cooper Surgical has done since they bought that company was use Chrissy Teigen’s huge Instagram account to advertise cord blood banking, and according to the article, Chrissy Teigen’s sales pitch has brought in 5,800 new customers. So she’s telling her 42 million or something subscribers to do this, and the Kelly Clarkson show also does this, and they did an episode. Or she advertises that stem cells are used to treat 80 different conditions, according to Kelly Clarkson. Dr Clarkson, the reporter, actually tried to track down the citation for this on social media and of course, it was just a wild goose chase, because it’s just a lie.
Antonia: 46:21
Yeah, Again, I encourage listeners to read this New York Times article. We’ll link to it. There’s lots of personal stories and other information in there. I think if you read through you probably will never recommend cord blood banking to any of your patients ever again, or at least you’ll be able to somewhat discourage the practice if people are asking about it or seem really intent on doing it.
Antonia: 46:45
It does rug me the wrong way a little bit about how some of the salespeople and promoters talk about the potential to treat conditions like saying it treats 80 different things, when it doesn’t. So one thing, for example, Chrissy Teigen has talked about is autism being a potential indication for cord blood transfusion, and that, of course, was totally debunked in this article. There was a few families interviewed that actually did try to access their banked cord blood for their child that later developed autism and they were denied because, at best at best it’s experimental and theoretical and there are no approved treatment protocols for using cord blood for autism and the clinical evidence says it doesn’t help at all. So, of course, combine that with the fact that there’s all these undisclosed bacterial contaminations and other issues, it really would be more likely that they could give their child a fatal bloodstream infection by using this rather than getting any benefit, at least for a kid with autism.
Howard: 47:51
Yeah, it’s a very sleazy kind of approach to advertising and giving people hope or false hope, I should say, for things like that and then times 80, not just autism, but it’s underhanded. Don’t you have a child with autism?
Antonia: 48:07
Yeah, and he’s mild or moderate on his assessment. He’s got a great prognosis, I think, for living life on his own one day and he’s just sweet and wonderful. So we wouldn’t want to change him at all and I’m sure a lot of parents would say that. So at least for me, if someone came up and said you should bank your cord blood so that you can cure his autism, I’d get pretty indignant and just tell him to go away and never come back. I can understand in more severe cases where the affected person is completely non-communicative and completely dependent for their whole lives. That’s a huge struggle and I can appreciate all the different avenues of research, especially into helping those kinds of people with severe disease. But it hasn’t panned out for cord blood for severe autism. So I think to keep dangling autism as a possible reason to do cord blood banking is truly sleazy. It’s just preying on people’s fears for no benefit sleazy.
Howard: 49:11
It’s just preying on people’s fears for no benefit. Yeah, okay, well, let’s move on. There was another new article in July 16th 2024 edition of the Annals of Internal Medicine and it was a survey asking women about their preferences for having mammography or delaying mammography after they were presented with the actual evidence about the risks and benefits of mammography. So they found that women in their 40s significantly increased their desire to wait until age 50 for the first mammogram when they were actually told about the risks and benefits of mammography in the 40s. I was happy to see this and happy to see a continued I’ll call it vigorous debate about mammography after the US Preventive Task Force Service revised their recommendation from 50 down to 40, as we discussed, really with no new evidence, and we discussed that, I believe, at the first episode of Season 7. But I do think that most patients and, frankly, most people who order mammograms don’t actually understand the risk-benefit ratio for mammography in the 40s for women who are otherwise considered low risk.
Antonia: 50:14
Yeah, we’ve talked about those risks before and none of that evidence has changed with the newly revised guidelines. The bottom line is that mammography from ages 40 to 50, when it’s done every year, does not reduce cancer deaths or total deaths from all causes, but it does expose 10% of those women to false positive findings. And also that includes complete breast cancer treatment for patients who actually never had breast cancer but they had a false diagnosis. So this study just shows that when a woman knows that mammography will not decrease the risk of her dying from cancer or from dying from anything it but will lead to unnecessary interventions and anxiety, then many women will choose to wait until 50 to start their mammography.
Antonia: 51:06
I definitely understand the strong undercurrent of irrational or I’d say rational fears as well about cancer, and maybe it’s a local cultural thing where I’m at now. But I definitely see people who have started their annual routine screenings before age 40 when they don’t really have the appropriate risk factors to qualify for that, and then they continue well into their 80s and even beyond that and are happy to keep doing that every year because no amount of information will reduce their lurking fears of the big C word. And I think once that fear has been instilled, it’s just living in them forever. It’s like, similarly to whenever I tell people who’ve been getting their annual PAPs that have always been normal. Hey, great news, the guidelines changed over 10 years ago 20 years ago.
Antonia: 51:58
yeah, and you only? Well, yeah, and you only need one every five years now, not every year. A lot of times the response to that is I had an aunt or a friend with ovarian cancer, so I would still like to keep getting my annual PAPs. Yeah, as if it checks for ovarian cancer?
Howard: 52:15
yeah, Right, right. And so this starts with primary care doctors and, honestly, an older generation of gynecologists, maybe some of the younger ones. We just have to keep providing accurate information, even though we can’t necessarily control how that information is received or judged, especially when it contradicts so many incorrect things that they might’ve been told to the patient from people who they trusted their longtime physician or whoever. But you are perfectly well-informed and unbiased, aren’t you? Are you going to start your own mammograms?
Howard: 52:47
at age 50, or what are you going to do? Not that you’re that old yet to have to make that decision?
Antonia: 52:53
Yeah, not yet, but it’s looming. I’m thinking I’ll for now go with the USPSTF recommendations and go every two years, starting at age 40, because I’ve got my own irrational fears, I guess as well.
Howard: 53:06
And that’s actually what the ACOG bulletin says is for us to inform the patient and then make a mutual decision about what the screening looks like. So that’s wonderful, there’s nothing wrong with that, and you can update us on how that goes, these new debates. I will just say that you talk about a woman getting yearly mammography from late 30s to 80. She’s probably going to get cancer from the mammography is the truth, but people don’t think that way yeah.
Howard: 53:30
These new debates about when to start mammography have more to do with minimizing the radiation exposure for that reason and so doing a mammography every other year in the 40s. Well, maybe that will work because the thought is that we’re going to reduce the harm, the radiation exposure and the false positives, while still maybe catching a breast cancer out of a thousand women, that before it becomes fatal. But that just hasn’t been actually demonstrated yet in scientific literature. But that’s the reasoning. So I’m glad this was published and that serious researchers are still trying to educate physicians and the public about this problem. And physicians and patients need to understand that mammography is nowhere near as valuable as they might think it is, especially for women in their 40s, is nowhere near as valuable as they might think it is, especially for women in their 40s, and that there’s really just little to support yearly mammography for women who are low risk in their 40s.
Antonia: 54:17
Okay, well, I think we might have time at least for one listener question, so let’s try to get at least through one of them. So our listener writes quote talk about performing cervical exams with sterile gloves. So I assume this is doing a digital exam to check for dilation in a pregnant woman. The sterile gloves cost 10 times as much as non-sterile gloves and there’s no evidence that non-sterilized gloves increase chorioamnionitis risk. Signed, cost Concerned in California.
Howard: 54:49
Yeah, that’s a great question and this would make a wonderful thing we do without evidence.
Howard: 54:54
And it’s a timely question because actually there was a randomized controlled trial published in June of 23 in the American Journal of Obstetrics and Gynecology, mfm, and I’ll put a link to that. And they randomized 163 women to those sterile polyvinyl exam gloves or to just the blue nitrile gloves that are hanging on the wall in the box as you walk in the room and they look for a difference in the rate of infection. And after 163 patients were enrolled they found a 5.4% rate of infection in the sterile group and a 4.4% rate of infection in the clean glove group. And they stopped the trial basically because they determined that at that rate more than 30,000 patients would need to be enrolled to find any even potentially statistically significant difference. On the other hand, they concluded that for them they would save about $25,000 a year at their hospital and they do about 3,500 deliveries each year. So our friend from California is absolutely correct and of course the only challenge is getting his hospital or her hospital to adopt that practice.
Antonia: 55:56
Yeah, this is another example of how far we’ve come.
Antonia: 56:00
It wasn’t too long ago that vaginal deliveries were treated like surgical procedures, where the patients were scrubbed with iodine and then prepped and draped as if they were having a surgery, and then the physicians would scrub in to a sterile surgical robe and gloves and then deliver the newborn. And a lot of other similar practices throughout the labor process were also undertaken to just try to make it as sterile as possible, and that included mandatory enemas and shaving the patient, both of which have long since been abandoned because we know now that they don’t make a difference. Vaginal delivery is not a sterile procedure and a vaginal exam is also not a sterile procedure, but all of this probably grew out of a reaction to the sins of the past, where they didn’t use any gloves ever and they would go from the morgue to caring for an entire ward of laboring patients without ever cleaning their hands once, and then they were transmitting fever and sepsis from patient to patient. And then dr semel vice went insane tragically, because he was shunned for speaking out against that practice.
Howard: 57:10
Yeah.
Antonia: 57:10
So it’s been opposite reaction.
Howard: 57:13
Well, we swing from one extreme to the other very often, but there is this phenomenon of, you know, we adopt a practice and then it’s just hard to get rid of it once it’s something that we do.
Howard: 57:22
And this is that inertia in our practice that I like to talk about. It’s easier not to adopt some new suggestion or intervention than it is to get rid of one that we’re currently utilizing, even if the levels of evidence are the same. And this is a cognitive mistake, it’s a bias, but it’s also a cognitive mistake to have a knee-jerk reaction to events that are associated with bad outcomes when they happen. So we see this with things like DVT or pulmonary embolism If we have one on our floor, which, of course, can be devastating and horrible in many cases, but also perhaps not always preventable. But the worst sin is sometimes is to adopt a whole bunch of practices that may not have actually made a difference for the affected patient but which are associated with harms themselves, like having a high rate of anticoagulation for all of our patients, because we just start seeing everybody is at risk and then that increases the risk of bleeding or other complications without actually decreasing the risk of death from DVT.
Antonia: 58:23
Yeah, and that’s a form of bias as well. The big secret here is just to always follow the evidence and not the emotions. In the same way, we often don’t do things we should because we haven’t seen the negative outcomes in our own practice that those interventions are supposed to prevent. It’s the same, it’s the different side of the coin, but it’s the same cognitive mistake.
Howard: 58:44
Well, I think we have time for one more question.
Antonia: 58:47
Okay, let’s do it. So I’ll read it. The listener says could you touch on TOLAC after two prior cesareans, so personal experiences and maybe success rates and how best to approach these patients, for example with allowing expectant management to a certain gestational age, and what’s the role for elective inductions based on prior obstetric history? And what’s the role for elective inductions based on prior obstetric history. Thank you, Signed Cesarean Scar Scared from Scranton.
Howard: 59:15
Okay, Well, just to be clear, you made that name up, but that’s not their actual signature. But I think it does reflect how a lot of us feel about questions like this in our clinical circumstance and that’s why they’re asking?
Antonia: 59:27
obviously yeah. If you imagine how people feel with just trial of labor after one cesarean in general, then this probably feels like brave new territory for a lot of folks out there with double the risks and double the liability.
Howard: 59:40
Well, yeah, and to answer the question, I think that my experience with a trial of labor after two cesareans today is much like my experience with a trial of labor after one cesarean today is much like my experience with a trial of labor after one cesarean, and if anything that you would allow in or do in the case of a person with one prior cesarean, you should probably do with two prior cesareans, which we talked about some of that in a previous episode, but I don’t think they’re treated any differently. Many, many years ago we allowed a trial of labor after two cesareans if the patient had had a prior vaginal delivery, and then we got rid of that requirement.
Antonia: 1:00:14
Yeah, and that requirement did make sense, at least theoretically, because it’s probably a little more reassuring to know that they’ve proven that their uterus can push out a baby out of their own pelvis, a baby that they have grown out of their own pelvis, a baby that they have grown. So if they’ve had a section and then a successful VBAC, or even maybe the other way around and then another section, then those patients would still be probably a more obvious, undebatable candidate for a trial of labor if they wanted. But not having had any prior vaginal delivery nowadays doesn’t rule out laboring, but it certainly is going to affect your estimation of what’s the chance it’ll succeed this time vaginal birth after cesarean allowed a trial of labor after two cesareans without the prior vaginal.
Howard: 1:01:12
But before that it was really the standard of care to support VBAC with two prior sections only if they had that prior vaginal. So I can remember the first time I managed a VBAC with no prior vaginal and then it was at least another 10 more cases like that before I started to become comfortable with the idea. But now it’s a fairly routine part of my practice.
Antonia: 1:01:33
There are some studies that have collected experiences of these practices, but most of them are going to be underpowered to see the rare outcomes, including uterine rupture. We can link to a study from 2022 that compared 793 patients with this history of two prior cesareans In that group. Most of them over 700 of them did have an elective repeat cesarean delivery, whereas only 82 of them had a trial of labor after cesarean and in their analysis there was one uterine rupture out of those 82 women who attempted a vaginal delivery and there were no ruptures in the planned repeat cesarean group. But overall there were no differences in other outcomes, either maternal or neonatal, including NICU admission, low APGARs, maternal hemorrhage or maternal need for blood transfusion, and there were no neonatal deaths.
Antonia: 1:02:24
Even that uterine rupture did not result in the baby dying. There were two bladder injuries and one bowel injury in the planned repeat C-section group. There was also one bladder injury in the trial of labor group, but those were not statistically significant differences. There were also six infections in the C-section group and none in the trial of labor group, but again, that whole thing was underpowered to find a difference with that outcome either. In other studies it seems like the uterine rupture rate for a person with two prior C-sections who’s now laboring is just over 1%, whereas in patients with one prior cesarean it’s roughly half that.
Howard: 1:03:06
Yeah, so it definitely makes sense that there should be a higher rate of uterine rupture if you’ve had two rather than one, but the truth is it’s about the 1% that everybody just tells patients. Anyway.
Howard: 1:03:17
when you discuss the risk with patients, everybody, I think, rounds to roughly 1%, whether they’ve had one or two, and so it’s where our estimation’s been, and you need a really large study that we don’t have to put a finer analysis on what the actual number is.
Howard: 1:03:34
But in that study that you’re talking about, about 70% of the women went on to have who tried had a successful vaginal delivery, and it’s hard to know if there’s much of a difference in the success rate that you might see and if you had an appropriately powered study of one prior cesareans versus those with two. Of course this is retrospective. The bad candidates maybe were talked out of it. There’s a lot we don’t know. Most patients who’ve had a second cesarean, though, have had it because they chose to not even try for a vaginal birth or they weren’t offered a vaginal birth, and so the fact that someone has had two cesareans honestly probably doesn’t change the potential success rate for a trial of labor that much, except that the obstetricians are going to be more nervous about it and biased towards having a low threshold for doing a section for almost anything because of that anxiety. So they may treat the patient with two prior cesareans differently than they might treat the one with one prior, but in a blinded way it might not matter.
Antonia: 1:04:29
Yeah, I could see how it would be different if someone had an arrest of descent and then a cesarean in their first birth, and then they attempted a trial of labor in their second birth and then had another cesarean for arrest of descent, and then now they have this third baby that’s estimated to be even bigger than the first two and they’re still wanting to labor. I think that’s probably a patient. I would advise not to try, like you probably shouldn’t try.
Howard: 1:04:58
Yeah, that sounds right to me.
Antonia: 1:04:59
But yeah, for most of the cases I see they had one C-section for some reason, maybe distress or a breach, and then they were not even offered a trial of labor.
Howard: 1:05:09
Yeah Well, overall, I think that I for one am fairly used to this. Now, these trials of labor after two cesareans, I do counsel them that the rupture rate is higher, and so we go through the risks and benefits just as we would with one prior, but the math’s a little bit different. And then to see if that math makes sense for them, especially in the context of future fertility plans, how big a family size do they intend, and things like that. But to answer the question, a trial of labor after two cesareans should be a routine part of obstetrics and that includes the options of augmenting and inducing and all those things. We don’t have any evidence that the recommendations about labor management should be different for two prior versus one prior.
Antonia: 1:05:51
All right. Well, I think we should wrap it up for the day. So the Thinking About OBGYN website will have links to the studies and articles that we talked about. So check that website out, check out our Instagram, and we’ll be back in a couple of weeks.
Announcer: 1:06:09 Thanks for listening. Find us online at thinkingaboutobgyn.com. Be sure to subscribe. Look for new episodes every two weeks.
