Thinking About Ob/Gyn

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

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Cervical cancer represents a success story in developed countries due to screening and vaccination, yet remains a significant global health problem with over 340,000 deaths annually worldwide. We explore the current state of cervical cancer prevention, screening, and treatment while discussing exciting advances that could eventually eliminate this disease.

• Different levels of prevention for cervical cancer: primordial, primary, secondary, tertiary, and quaternary
• HPV vaccination as the most effective primary prevention method, with Australia on track to make cervical cancer rare by 2035
• Evolution from Pap smears to primary HPV testing, with potential future urine-based screening options
• Less radical surgical approaches for early-stage disease, improving quality of life without compromising outcomes
• Immunotherapy advances showing 6-12 month survival benefits in metastatic disease
• Howard Kelly's pioneering work with radium in the early 1900s, establishing foundations for radiation therapy
• Importance of addressing healthcare disparities, as rural Americans are 25% more likely to develop cervical cancer and 42% more likely to die from it

Visit our website at thinkingaboutobgyn.com for more information and follow us on Instagram for updates.

00:00:00 Introduction to Cervical Cancer

00:08:10 Prevention Strategies Explained

00:18:02 HPV Screening Evolution 

00:26:51Treatment of Early-Stage Disease

00:37:09Advances in Locally Advanced Disease

00:50:31 Radium and Howard Kelly's History

01:02:48 Final Thoughts on Prevention

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Howard and Antonia explore the evidence behind pit breaks in labor, cannabis use in pregnancy, and IUD options for hormone replacement therapy.

• Pit breaks in labor lack substantial evidence of benefit when used in active labor
• Current research suggests stopping oxytocin during active labor may slightly increase cesarean rates rather than decrease them
• Long pit breaks (up to 8 hours) in latent labor may be beneficial by allowing rest and promoting patience
• Recent systematic review shows prenatal cannabis use increases risk of low birth weight by 75%, preterm birth by 50%, and perinatal mortality by 29%
• Cannabis use during pregnancy (7.2% of pregnant women) now exceeds tobacco use
• Retrospective studies on doula care show association with better outcomes, but can't establish causation due to inherent differences in patients who seek doulas
• 52mg levonorgestrel IUDs (Mirena/Liletta) are suitable for endometrial protection during HRT, but evidence only supports use up to 5 years
• Most systematic reviews combine heterogeneous studies and shouldn't be considered level 1 evidence

We'd love to hear your questions! Send them to us through our Instagram or website thinkingaboutobgyn.com.

00:04:52 Pit Breaks in Labor

00:15:32 Examining Evidence on Oxytocin Discontinuation

00:26:08 Prenatal Cannabis Use and Adverse Outcomes

00:36:07 Doula Care Study Analysis

00:57:22 Levonorgestrel IUD Use in HRT

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Join Howard and Janeen Arbuckle for this discussion of pediatric and adolescent gynecology essentials. Pediatric and adolescent gynecology is a newer discipline bringing specialized care to young women with unique gynecologic needs, with a focus on counseling, education, and age-appropriate interventions.

• Abnormal uterine bleeding in adolescents is rarely caused by structural problems (unlike in adults) and typically relates to immaturity of the hypothalamic-pituitary-ovarian axis
• Hematologic workup should be considered for adolescents with heavy menstrual bleeding as this may be the first time their clotting system is challenged
• Hormonal therapies are safe to use once menarche has occurred, with no impact on bone growth
• Long-acting reversible contraceptives offer superior pregnancy prevention (1 in 10,000 for implants vs 8 in 100 for typical pill use) but require thoughtful counseling
• Private interviews with adolescent patients create trust while preparing them for independent healthcare navigation
• Tranexamic acid is effective for heavy menstrual bleeding in adolescents but pill size and frequency can limit compliance
• Most ovarian cysts in adolescents represent normal physiologic function and rarely require intervention
• Preservation of reproductive organs should be prioritized in adolescent surgery, including leaving ovaries after torsion when possible
• Vaginal bleeding in pre-pubertal girls requires assessment for secondary sexual characteristics to distinguish precocious puberty from other causes

00:00:00 Introduction to Pediatric Gynecology

00:07:20 Abnormal Uterine Bleeding in Adolescents

00:19:36 Contraception Choices for Young Patients

00:29:40 Managing Difficult Patient-Parent Conversations

00:38:04 Pelvic Pain and Endometriosis

00:46:58 Adnexal Pathology and Ovarian Issues

00:50:51 Congenital Anomalies and Vaginal Bleeding

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In this episode, Antonia and Howard explore the groundbreaking study on treating male partners for bacterial vaginosis, revealing significantly reduced recurrence rates and challenging our traditional understanding of BV pathophysiology.

Plus: 

• Evidence doesn't support treating mild gestational hypertension with antihypertensives
• Studies confirm acetaminophen in pregnancy doesn't cause ADHD or autism
• New research questions the benefit of routine postpartum thromboprophylaxis

• The history of heparin and coumadin

00:00:34 Treating Mild Hypertension in Pregnancy

00:06:14 Distinguishing Chronic vs. Gestational Hypertension

00:15:46 Male Partner Treatment for Recurring BV

00:27:09 Understanding Bacterial Vaginosis Pathophysiology

00:35:42 Ineffective Treatments and Alternative Approaches

00:53:04 Tylenol in Pregnancy: Debunking ADHD Claims

00:58:02 Postpartum Thromboprophylaxis: Evidence Against Overuse

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This episode features our favorite podcast ninja, Dr. Maddie White. She and Howard discuss how medical dramatizations misrepresent obstetric emergencies (yes, we are watching The Pitt). Then, we dissect evidence-based approaches to common triage scenarios including labor evaluation, rupture of membranes, and preterm labor assessment.

• Television shows like "The Pitt" and "ER" portray shoulder dystocia and postpartum hemorrhage inaccurately, lacking proper urgency and technique
• Hospital-based labor triage often costs approximately 10 times more than office-based evaluation, often without clinical benefit
• Understanding pretest probability fundamentally changes how test results should be interpreted for suspected rupture of membranes
• Most expensive tests like Amnisure (>$500) provide minimal additional value over traditional approaches when interpreted properly
• Evidence doesn't support routine use of fetal fibronectin testing in preterm labor evaluation
• We discuss universal cervical length screening for prevention of preterm labor in the midtrimester and later in pregnancy for evaluation of threatened preterm labor

00:00:53 Critiquing Obstetric Emergencies in TV Shows

00:10:13 Proper Management of Shoulder Dystocia

00:14:52 Postpartum Hemorrhage Management Approaches

00:19:59 Evaluating Term Labor Complaints

00:25:35 Rupture of Membranes Testing Strategies

00:34:12 Understanding Test Probability and Performance

00:42:26 Cervical Length Screening Evidence

00:51:23 Preterm Labor Triage Tools

01:00:23 Concluding Thoughts on Evidence-Based Practice

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