In this episode, Howard and Maddie White challenge shaky claims linking autism to circumcision and Tylenol, then zero in on speed as the byproduct of essential, evidence-based surgery. We show how essentialism, confidence, and efficiency reduce complications, lower costs, and improve outcomes in the OR.

• correlation vs causation in autism narratives and bias in research
• why operative time predicts complications across procedures
• surgeon volume, variability, and outcome differences
• evidence-based cesarean steps that cut time and bleeding
• tool and method choices that are safer and faster
• confidence as self-efficacy, not arrogance
• practical efficiency: setup, flow, visualization, debrief
• lean thinking, standardization, and reducing variation

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

00:00:00 Opening Banter & Autism Claims

00:02:35 Circumcision, Bias, and Correlation vs Causation

00:09:54 Why Speed in Surgery Matters

00:15:35 Surgeon Variability and Outcomes

00:19:35 Evidence-Based Cesarean: Essential Steps

00:27:20 Less Bleeding Through Minimal Dissection

00:31:20 Choosing Methods and Tools that Save Time

00:35:05 Confidence vs Arrogance in the OR

00:40:05 Practical Efficiency: Filming, Flow, and Setup

00:45:05 Visualization, Assisting, and Debriefing

00:50:00 Tools, Tech, and Mastering Basics

00:55:00 Standardization, Lean Thinking, and Takeaways

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We push back on claims that Tylenol or vaccines cause autism and explain how weak methods, conflicts of interest, and cherry-picked data fuel public panic. We also unpack why diagnoses have risen—broad criteria, screening, and access—not because of a new environmental villain.

• Summary of claims made at the press event and why they fail
• What the cited acetaminophen paper did and didn’t show
• Conflicts of interest, pay-to-publish venues, and bias
• Why correlation isn’t causation; confounding by indication
• Bradford Hill criteria applied to acetaminophen and autism
• Sibling-controlled studies as the strongest current evidence
• Amish and Cuba myths; diagnosis versus true prevalence
• DSM-5 changes driving higher autism diagnoses
• State-by-state variation explained by services and funding
• Vaccine safety evidence contrasted with myths
• Practical counseling: treat fever; use clear, strong evidence

Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram

0:00 Setting The Record Straight

2:30 The Press Conference Claims

5:30 Tylenol, Vaccines, And Autism

9:30 The Study Behind The Hype

14:30 Conflicts, Bias, And Bad Methods

19:30 Correlation Isn’t Causation

23:00 Bradford Hill 101

28:30 Amish, Cuba, And Diagnosis Rates

33:30 Screening Tools And Subjectivity

37:30 Sibling Studies: The Strongest Signal

42:00 Why Meta-Analyses Can Mislead

46:00 What The “Navigation Guide” Misses

51:00 Vaccine Myths In Perspective

54:00 Why Autism Diagnoses Rise

59:00 DSM-5 And Access To Services

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Dr. Howard Herrell explores common questions about birth alternatives posed by Anna, a mom-to-be with questions, examining scientific evidence behind claims often found online that challenge evidence-based obstetric practices. The discussion separates facts from philosophy by analyzing actual research data on interventions like epidurals, oxytocin, and birthing positions.

• Maternal mortality has decreased 173-fold since 1850, coinciding with the rise of modern obstetrics
• The "cascade of interventions" theory isn't supported by scientific evidence
• Studies show epidurals don't increase cesarean delivery rates, contrary to popular belief
• Oxytocin augmentation, when properly used, can decrease cesarean rates rather than increase them
• Upright birthing positions don't show improved outcomes compared to lying on back
• Hospital/provider cesarean rates matter more than specific interventions in predicting your risk
• For low-risk pregnancies, intermittent rather than continuous fetal monitoring may reduce unnecessary interventions
• Best approach combines respecting physiologic birth while using appropriate medical tools when needed

Visit thinkingaboutobgyn.com for more information and follow us on Instagram. We'll be back in two weeks.

00:00:02 Introduction to Natural Birth Questions

00:02:09 Historical Maternal Mortality Statistics

00:05:54 Nutrition Myths and Modern Food Safety

00:11:34 Debunking the Cascade of Interventions Theory

00:21:32 Epidurals: Facts vs. Misconceptions

00:35:59 Birth Positions and Perineum Protection

00:44:20 Avoiding Unnecessary Cesareans

00:48:56 Continuous vs. Intermittent Fetal Monitoring

00:56:24 Artificial Rupture of Membranes Discussion

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Howard and Antonia explore the safety of medications during pregnancy and the controversial reporting requirements for breast density on mammograms, examining how science is being overshadowed by fear-mongering in healthcare decision-making.

• Examining the evidence behind avoiding fluconazole (Diflucan) in first trimester, finding that short courses likely pose minimal risk
• Discussing the important distinction between possibility and probability when evaluating medication safety in pregnancy
• Analyzing the wide variation in cesarean delivery rates across US counties, from 5.4% to over 53% for low-risk patients
• Critiquing politically-motivated FDA actions on SSRIs, food dyes, and other health policies not supported by scientific evidence
• Explaining why the FDA's requirement to notify women of dense breasts on mammograms may cause more harm than good
• Demonstrating how supplemental testing for women with dense breasts leads to false positives and unnecessary procedures
• Reviewing the historical development of prenatal diagnosis from early ultrasound to cell-free DNA testing

00:00:33 Evidence for Diflucan in Pregnancy

00:12:12 Cesarean Delivery Rates Across US Counties

00:16:39 FDA's Position on SSRIs and Food Dyes

00:28:46 Managing Dense Breasts in Mammography

00:44:46 History of Prenatal Abnormality Diagnosis

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Dr. Jacqueline Vidosh shares her powerful journey as both an obstetrician and mother to Noah, who has trisomy 18, challenging traditional medical understanding of this condition and providing insights into compassionate patient care. Her story, recently featured in The New York Times, illustrates how medical perspectives on chromosomal conditions can evolve through lived experience, highlighting the spectrum nature of trisomy 18 and the importance of accurate, unbiased counseling.

• Receiving the diagnosis during pregnancy and navigating the emotional process when medical training suggested a fatal outcome
• Discovering that trisomy 18 exists on a spectrum with possibilities beyond what medical textbooks described
• Managing Noah's complex medical needs including ventilator, tracheostomy, and gastrostomy tube while balancing family life
• Advocating for appropriate medical interventions by challenging the assumption that care would be "futile"
• Celebrating Noah's achievements and joys – his love of music, lights, and his unique ways of communication
• Recent medical literature supporting interventions for trisomy 18/13 on a case-by-case basis
• Using the SPIKES protocol for delivering difficult news with respect and compassion
• Implementing trauma-informed care for families experiencing complicated pregnancies and NICU stays

Read more about Noah's story in The New York Times article, available through the free link provided in our show notes.
https://www.nytimes.com/2025/07/31/magazine/trisomy-18-edwards-syndrome-baby-treatment-care.html?unlocked_article_code=1.ak8.JRBu.7-qMQhelsVYx&smid=url-share

00:00:00 Introduction to Trisomy 18 Discussion

00:08:40 Receiving the Diagnosis

00:17:45 Challenging Medical Assumptions

00:27:30 Noah's Daily Life and Care

00:38:20 Joy and Connection with Noah

00:47:10 Navigating the Medical System

00:54:00 Breaking Difficult News Effectively

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Recent evidence challenges the practice of prescribing oral antibiotics after Cesarean delivery in obese patients, finding no significant reduction in infection rates compared to standard preoperative antibiotics alone. Howard and Antonia analyze studies showing why this once-promising intervention may not be necessary.

• ACOG updates delayed cord clamping guidance to minimum 60 seconds for preterm infants
• Baby born at 21 weeks and zero days celebrates first birthday, highlighting advances in neonatal care
• Systematic reviews show no difference between chlorhexidine and iodine for vaginal prep before hysterectomy
• Conservative management of placenta accreta spectrum disorders shows improved outcomes over immediate cesarean hysterectomy
• Labor arrest Cesareans have highest blood loss among non-accreta cesarean indications
• New HPV testing terminology recommends "HPV detected" rather than "positive" to avoid relationship misunderstandings
• USPSTF preeclampsia prevention guidelines classify 89% of pregnant women as aspirin candidates despite limited evidence
• Endometrial sampling best practices include stepwise approach starting with ultrasound before considering hysteroscopy

In two weeks, Jacqueline Vidosch returns to discuss her son Noah who has trisomy 18, following a feature in the New York Times.

00:00:00 Episode Introduction

00:06:43 Post-Cesarean Antibiotics: Evidence Review

00:17:11 Delayed Cord Clamping Updates

00:22:13 Extreme Preterm Survival Case

00:26:40 Vaginal Prep and Placenta Accreta Management

00:30:11 Cesarean Blood Loss by Indication

00:34:21 HPV Testing Language Changes

00:37:45 Aspirin for Preeclampsia Prevention

00:51:33 Endometrial Sampling Question

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Dr. Scott Guthrie joins us to explore the significant advances in neonatal care and the critical partnership between obstetricians and neonatologists to improve outcomes for newborns. Highlights include: 

• Successful implemented delayed cord clamping across Tennessee hospitals through collaborative quality improvement project
• Neonatal mortality has decreased 30% between 1999-2022 due to advances in medical care and prenatal management
• Survival rates for 22-week premature infants have improved to 30-40%, with many having normal development
• Modern ventilation strategies now allow extremely premature babies to avoid intubation completely
• Delivery room practices have shifted from routine suctioning to prioritizing effective ventilation
• Therapeutic cooling has revolutionized treatment for hypoxic ischemic encephalopathy when initiated within 6 hours
• Historical treatment of meconium stained fluid has evolved as we better understood its pathophysiology
• Neonatal intensive care advances were catalyzed by Patrick Kennedy's death from hyaline membrane disease in 1963

Join us for our continuing exploration of obstetrical and neonatal advances as we work together to improve outcomes for mothers and babies.

00:00:00 Introduction to Neonatal Care Advances

00:10:13 Neonatal Mortality Trends and Challenges 

00:16:27Technological Evolution in NICU Care

00:24:07 Periviable Infants: Improved Survival Rates

00:31:09 Delivery Room Best Practices for Newborns

00:38:44 Modern Meconium Management Approaches

00:47:19 Therapeutic Hypothermia for HIE

00:55:42 Causes and Detection of Hypoxic Ischemic Encephalopathy

01:03:01 History of Neonatal Care Evolution

01:12:25 Concluding Thoughts on Collaborative Care

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Howard and Antonia dive into their tenth season with a critical look at several new studies. Topics include:

• Estrogen-soaked vaginal packing after surgery lacks evidence for benefits while carrying unnecessary costs
• Recent studies on vaginal birth after cesarean deserve careful interpretation beyond aggregate outcomes
• Hospital uterine rupture rate is 0.2-0.4%, with only 8% resulting in catastrophic outcomes when properly managed
• Warnings against infant co-sleeping date back to ancient times, predating modern pediatric recommendations
• Vaginal hysterectomy continues to decline despite shorter OR times, lower costs, and similar complication rates
• Swedish study shows only 25% of ideal candidates receive vaginal hysterectomies, with projections showing disastrous decline in rates of appropriate surgeries

Stay tuned for our next episode featuring Scott Guthrie discussing neonatal resuscitation and other neonatal concepts important for OB-GYNs to understand.

00:00:00 Season 10 Introduction

00:01:13 No Evidence for Estrogen Packs After Surgery

00:10:35 VBAC Studies: Interpreting Maternal Risks

00:19:12 Catastrophic Uterine Rupture: Hospital vs Home

00:28:53 King Solomon and Infant Co-Sleeping Dangers

00:39:50 Vaginal Hysterectomy: Declining Despite Evidence

00:54:09 Cost and Time Analysis of Hysterectomy Routes

01:06:24 Closing Thoughts on Season 10

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Surgical techniques in gynecology vary widely between surgeons, creating both excitement and frustration for residents trying to learn the "right way" to perform procedures. Howard and guest host Maddie White discuss this and more:

• Trocar placement during laparoscopy requires careful consideration of patient factors and potential adhesions
• Elevating the abdomen during trocar placement remains standard practice, though definitive evidence on its necessity would require studies of over 100,000 patients
• Surgeons should understand power analysis to recognize when studies are underpowered to detect meaningful differences in rare complications
• Visceral slide technique using ultrasound can identify adhesions and determine the safest entry point for laparoscopic surgery
• Palmer's point may no longer be the safest entry point for many patients given the prevalence of bariatric surgeries
• Jain's point (lateral to the umbilicus) may now be statistically safer for many patients with complex surgical histories
• Vaginal cuff dehiscence rates are 6-10 times higher with laparoscopic/robotic hysterectomy compared to vaginal approaches
• The higher dehiscence rate stems from using energy devices for colpotomy rather than cold scalpel techniques
• Barbed sutures simplify cuff closure but don't reduce dehiscence rates compared to standard suturing techniques
• Surgery consists of "a thousand little things done well" - mastering these micro-skills distinguishes excellent surgeons

00:00:00 Surgical Techniques: Excited and Frustrated

00:08:00 Elevation During Trocar Placement 

00:17:00 Evidence and Power Analysis

00:21:35 Visceral Slide Technique

00:35:10 Alternative Trocar Entry Points

00:40:10 Cuff Closure and Dehiscence Risk

00:51:45 Laparoscopic vs Vaginal Colpotomies

01:03:00 First Accredited OB-GYN Residency Program

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Howard Herrell and Antonia Roberts explore evidence-based practices in obstetrics and gynecology, examining both established protocols and emerging research with critical perspectives on medical misinformation.

• Serial cervical length monitoring after LEEP procedures lacks evidence for improving outcomes despite being common practice
• SMFM's 2016 recommendation explicitly advises against routine cervical length screening for patients with history of cervical procedures
• Retrospective studies on induction timing require careful interpretation due to inherent biases in methodology
• Understanding the difference between intent-to-treat and per-protocol analysis is crucial when evaluating medical research
• Pseudoscience and alternative medicine have gained mainstream acceptance over decades through celebrity endorsements and media platforms
• Reusable surgical instruments like stainless steel uterine manipulators offer both economic and environmental advantages over disposable options
• Plus, Learn the history of The Green Journal's distinctive color

Be sure to check out thinkingaboutobgyn.com for more information and follow us on Instagram. We'll be back in two weeks.

00:00:35 Monitoring Cervical Length After LEEP

00:10:30 Understanding Intent-to-Treat Analysis

00:28:54 MAHA Movement and Medical Misinformation

00:53:49 Carbon Footprint of Uterine Manipulators

00:57:30 History of the Green Journal

Follow us on Instagram @thinkingaboutobgyn.