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This episode is brought to you by Jack Daniels. Jack Daniels and music are made for each other. They share a rhythm in the craft of making something timeless while being a part of legendary nights. From backyard jams to sold out arenas, there's a song in every toast. Please drink responsibly. Responsibility.org, jack Daniels and Old no. 7 are registered trademarks. Tennessee Whiskey 40% alcohol by volume. Jack Daniel Distillery, Lynchburg, Tennessee. All right, are you feeling here? The anesthesia staff will make sure that you are numb or asleep before starting surgery right here. The surgery for your cesarean birth will take about There is no shortage of patient friendly videos out there online regarding cesarean section and even some that aren't necessarily for patients. There's plenty of procedural recaps and procedural techniques on C section online and some are good and some are not so good, but nonetheless, C sections are online in a variety of different fashions and modes. You and your birthing partner will probably be able to touch and hold your well, this relates to what we're talking about because just 24 hours ago, just 24 hours from when we're recording this, I received a message through one of our podcast social media channels that was extremely timely because literally something just came out in an international journal recently regarding this very question. I thought, oh hey, somebody's been reading their international journals. So my first question was, hey, are you in the UK or are you here in the us? And the person who asked the question said, no, I'm here in the us I'm a senior resident in OB GYN and had a question regarding this very issue of changing gloves after placental delivery and before hysterotomy closure. If that was something that is evidence based. Because I have one faculty member that definitely advocates for that, but that's pretty much the only person in our department. And our department is, we feel is pretty evidence based and pretty academic. So what are we missing here? That was a question that I received. So I responded back and I said, well, perfect timing, perfect timing because on November 13, 2025 out of the journal Hospital Infection. Yeah, I'm sure we all subscribe to that. On November 13, 2025 in the journal Hospital Infection, this was actually looked at in the UK model right through the national and the title was Glove Changed During Cesarean Birth Impact on Maternity Service Budgets and Capacity. Now that was not a true patient follow up study. That was a math model seeing if it was cost effective to change gloves after placental delivery and before abdominal wall closure. Now why was it even Asking this question. Well, the answer is super easy because there is absolutely data back based on some RCTs and even systematic reviews and meta analyses. The last one was in 2021 that show, hey, to prevent wound infection. This may be a thing, but. But wait, but hold on. This is where, guys, here's. Here's the tag. Here's one of the clinical pearls. Having data is sometimes different than having globally applicable data. Okay, Having data, because there is data there. So the question is, is there data to support changing gloves? Or as a cheaper alternative to that, even just washing gloves, which, in all disclosure, I did train with that. There was a physician back in Dallas county who advocated for this, and he was a legend, a pillar in maternal fetal medicine. And so after the placenta was out, we would wash our hands, our gloves in this little basin of sterile water, like Pontius Pilate. And then he'd say, Proceed, Dr. Santos, God bless him. I mean, just wisdom, wisdom beyond his age, even though he was pretty old at that time anyway. So, yes, I did train with that and I thought, this is weird. He's the only one who does this. So this has been a thing for some time. So that question that came into our podcast episode, guys, should we change gloves at C section after the placenta is out? It has been around for a while now. I want to say two things of why this is super timely and why I said, hey, are you in the UK or the US Is because this is a kind of a thing, much more of a thing, or at least much more applicable in the United Kingdom than through nhs. And I'm going to give you why I say that in a minute. Nothing wrong with nhs. We've got plenty of podcast family members in the UK and thankful for them. But it is a different model, maybe different care bundles. Actually, I know they have different C section bundles because there may be. While ACOG and the Royal College do have some similarities, there's some things that. Where they're actually not the same. Okay, so we'll talk about some of those in their green top recommendations. But this is a bigger thing potentially in the NHS system because of its universal health care system and trying to keep patients out of the hospital and. Or even in the clinic, because all of that is through the nhs, may be more valid because that's kind of a different model than for us. Plus, more importantly, in this November 2023 publication that we're going to talk about in the Journal of Hospital Infection, they use a number, a benchmark of what they consider to be A baseline percentage of post C section wound infections that is significantly higher than we have here in the us and that's why if you set the bar higher, you've got much more room to improve. So we got to talk about these things because they gave a 30 day post discharge SSI rate, surgical site infection rate, that's pretty much double what we should expect here in the us so that's the first thing. So, yes, there is data on November 13, 2025 that this potentially may be cost effective based on which model you're looking at. But even go goes back to September of 2025. And guys, remember, we're doing this in November of 2025. So just two months ago, Figo released their, quote, new guidance on preventing cesarean section sepsis, end quote. Now remember, this is figo, so this is taken into account. Everybody from an international perspective. This is why when Figo or the World Health Organization says something, you have to put it into the perspective of global health, not necessarily U.S. health or Canadian health, South American. They're assuming different populations here, some of which have higher risk than we have in the US because of our care bundles. Okay, so this is why this is super timely. So again, I'm just in the intro and I'm going to set this up because the question is change gloves after placenta at C section, yes or no. And the answer is, well, it's complicated. And it's complicated because, yes, there is absolutely data, yes. It's even in Figo's update on preventing post cesarean section sepsis from September of 2025. I'm looking at it right here in my screen. Intraoperative quote, change gloves prior to closure of the abdominal wall, end quote. It's in figo. So if somebody tells you, well, there's no data, you go, not true. There's absolutely data for it. However, as we mentioned, having data is different than applicable data. Having data is better. It's not the same thing as having high quality data that's free of bias. So we're going to answer these questions. Does acog, the cdc, does smfm, do they endorse glove change or glove washing after placental delivery? And if they don't, why not? When there's clearly randomized trials and clearly systematic reviews and meta analyses like the one in 2021 that showed that it works, Figo's onto it. Figo says, yes, and apparently this brand new November 2025 cost analysis from the UK said we can do it. So somewhere there's either a disconnect or we have to understand the data. Let me spoil it for you. The answer is we have to understand the data. So I think I've set it up enough. Now that we've done all that, let's get out of the intro. We've got some fun stuff to cover here. Change gloves after placenta Etsy section, yes or no? Well, it is a little complicated, but we're gonna make it super easy. Coming up next, every holiday shopper's got a list, but Ross shoppers, you've got a mission like a gift run that turns into a disco snow globe, throw pillows and PJs for the whole family, dog included. At Ross, holiday magic isn't about spending more, it's about giving more for less. Ross, work your magic. This is Dr. Chapas ob Gyn no Spin podcast. This is a fascinating question and again, perfectly timed since we do have stuff in print. Figo released something two months ago. We have this new publication from this month, November 2025. From an international perspective that looked at this, but. But it's kind of a novel concept and super easy to adopt, right? Hey, change your gloves sterile before you close the uterus and definitely before you close the skin after potential extraction. Seems pretty easy or, or at the minimum. Then rinse your gloves off, as we mentioned in our intro. God bless the memory again of Dr. Santos. Or you know, just clean them off in some aspect so you don't continue your contaminated gloves, so to speak, because you've touched inside the uterine cavity which connects obviously to the vagina. Hence that's why C sections are clean, contaminated surgeries. And so it's an easy to adopt issue. Totally. However, even though that is super reasonable and there's absolutely data on it, the major professional societies right now don't include that. And I'll be very clear in none of the evidence based C section techniques that have been published mainly out of the gray journal and that we have covered on this show as well by Dalk et al. There's been several revisions from that. The first one was in 2013. And then of course you have even the eras protocols, which part two of the enhanced Recovery After Surgery protocol has to do with with intraop care. There's nothing in there about washing or changing your gloves after placental delivery or extraction. Nothing in it. So ACOG doesn't say anything about it, SMFM doesn't say anything about it. CDC doesn't say anything about it and it's not in the ERAs protocol. So there's obviously some kind of disconnect here. Right. Because if there's enough for Figo to recently publish this in their International perspectives. And again, that was released on September 9, 2025. If Figo says, hey, this is an easy to adopt thing, then why does acog, CDC and SMFM go, yeah, now we're just not gonna do that. So there is definitely a disconnect. So somewhere and in this episode, we're gonna get there, we're gonna put this issue on trial. You know, we've done this before. I like to do that. So, yep, in this section and we're going to put changing gloves in court and we're going to take it to court and we're going to play both sides. We're going to be both the attorney for the defendant, which is changing gloves, thank you very much. And we're going to say, hey, wait a minute, wait a minute, wait a minute. There is definite data that this is a thing. And so we are going to make the case that changing gloves at C section can help reduce ssi because again, that's enough buy in for Figo to say, maybe you should do that. Thank you very much. All right, so on one case would be the. Will be the. The lawyers. Is that the plaintiff or the defendant? Who. What are we saying? I guess it's the. The. The defendant. Sure. I mean, changing the gloves. If that's the accused, then we're going to defend its case saying, yes, there is. However, we will also be playing the part of the plaintiff, accusing that of not a good. Not enough data. Okay. Not enough evidence. So we're putting once again the issue of changing gloves or cleaning gloves at C section on trial. And we're gonna look at both sides. We're gonna tackle first the side that says, yes, we are right, you should do it. There's evidence for this, including meta analysis and systematic reviews. So we are correct. Then after we do that, we're gonna come back and we're gonna t side going, yes, you do have data. But. And that's the. But that's the reason why right now, as of November 2025, it is not in guidance. Now, let me be very clear. I have no problem if you want to do this at all. I mean, the most cost effective isn't even to change your gloves is just to wash them either again in the little punches pilot kind of bowl of water, as Dr. Santos taught me, or with a wet gauze to wipe your hands off before you do hysterotomy closure. That's the most cost effective. Just rinse them off what? What does that cost? Nothing. You already got saline on for irrigation if you're going to do that anyway. So I have no problem doing this. And they are both right. Is there data to do this? Absolutely. Is it reasonable to do it? Yes. Is there a harm to do it? Zero. So why not? So that's the stance that we're going to, that we're going to say first as we defend this. And very quickly, guys, just very quickly, I'm just going to give you the quick data and the risk reduction that according to a Systematic Review from 2021 said, yes, this is valid, but then we're going to leave that and then we're going to come back and do the rebuttal where ACOG and CDC says, I hear you, I get that. However, I just like that a lot. However, we're not going to do it and here's why. So we are going to put this together first, I think let's go ahead and tackle this issue. We're going to put the first thing on, on our stance, which is the stance that yes, this does work. There is definitely data on this and we should do that. So we gave our little gavel. Let's go ahead and get started on this. And first we're going to make the case that the data is sufficient to do it. Now, plenty of data have looked at this, including randomized trials, and the last one that we've already mentioned was in 2021 and absolutely it did find that this was effective. However, it was effective only for the reduction in wound infection, not in endometritis. Okay. There was no significant difference in endometritis, which is kind of weird, or febrile morbidity. So if you're asked, if you're going to do this, what are you trying to prevent? It seems that according to the systematic reviews and meta analysis, the latest of which was by Neurice et al in 2021, that it's really good for reducing wound infection only. Okay. The relative risk reduction was 0.41 with a confidence interval that was under 1. It was 0.26 to 0.65. So it's fine. The quality was graded as well, mild to moderate, and that's one of the issues. Okay. So the benefit was observed when gloves were changed after placental delivery and before closure, but no significant difference in the incidence of endometritis or febrile morbidity. So these authors said while glove changing after placental delivery reduces post surgical wound complications. Now here's the catch, guys. Here's where they cook their own goose. Further adequate powered studies are needed to address limitations and the cost effectiveness before routine adoption in clinical practice. End quote. So there you go. So they kind of hedge their bet there a little bit. And the reason they hedge their bet is why acog, CDC and SMFM have not adopted because they're like, look, we've got good skin prep, predominantly with chlorhexidine. You can do vaginal prep. You can consider that if that's a thing, especially if they're ruptured or in labor. And then the addition of Zithromax for those ruptured, for those who are intrapartum and or for those who have obesity, that was added most recently based on the ERAS protocol, which we covered. And we've got better ways to reduce infection because the quality of this data, guys, and here's the catch. The quality of these data was meh. It really wasn't great. Even the authors of the systematic review and meta analysis said, yes, this can reduce post surgical wound infections. We see it. However, we need more data that are adequately powered because there's a lot of limitations here and we're not sure if this is really ready for adoption universally in clinical practice. Okay, now remember, Figo went with this. Figo used this in September 2025 because it's low risk and it's relatively low cost. And why not from an international perspective? All right, so once again, that is the 2021 NARIS study that was the most comprehensive to date. And that was an ACTA Obstetrics and Gynecology Scandinavia. All right, so ACTA in 2021, this is called et al paper which was the systematic review and meta analysis. So as we are the attorneys defending this practice that says yes, there is data and we've got cost effectiveness now addressed because that was what was released in November of 2025. Why not Ford BlueCruise Hands Free highway driving takes the work out of being behind the wheel, allowing you to relax and reconnect while also staying in control. Enjoy the drive in BlueCruise enabled vehicles like the F150 Explorer and Mustang Mach E. Available feature on equipped vehicles Terms apply. Does not replace safe driving. See Ford.com BlueCruise for more details. This episode is brought to you by State Farm. Listening to this podcast Smart move. Being financially savvy Smart move. Another smart move having State Farm help you create a competitive price when you choose to bundle home and auto bundling. Just another way to save with a personal price plan like a good neighbor State Farm is there. Prices are based on rating plans that vary by state. Coverage options are selected by the customer. Availability, amount of discounts and savings and eligibility vary by state. Well, the catch is this publication that showed it was cost effective again out of the Journal of Hospital Infection was a math model. So it wasn't a true follow up, it wasn't a real economic evaluation. It was based, number one, on the nhs. So it's unclear if that extrapolates well to the US system. And they used a benchmark. They said we're going to assume a 30 day chance of reinfection or of chance of readmission rather for wound infection, that's. And we're going to set that number at 15%. Okay, so now that's just a number that they came up with, quote, based on the current 30 day post discharge SSI rate of 15%, yada, yada, yada. Okay, so they're using, if we start at 15%, most things are going to have a drop on that because it's pretty high. Now, in the US in general, for just any kind of surgery, the chance of a wound infection is based on who you read, but can be as high as about 3%. Okay. For C sections specifically, because it's clean, contaminated, because we enter again the GU tract, that raises up to double that. So most put the estimate at about 6% in the general C section population. Higher risk populations like obese, bad diabetes maybe, or poor nutrition, you double that number. So now you go to 12%. All right, so general chance of SSI wound infection in surgery overall is about 3%. In C section it is double that of 6%. And then in high risk you double that and it's 12%. So that's why things, when they're easy, they're easy to remember. And this one works out because you just double starting from 3%. All right, so 3% in general, 6% for C section and then in obese C sections it's double that. So it's 12%. So this study from the UK used a benchmark that was even higher than that, that was 15% and said, hey, based on this model, this thing works. Yeah, we could possibly do this since we're all connected to one payer system of the nhs. Whether they come to the clinic or they get readmitted, it's all costing the system more money. Which again may be different in the US because we've got different outpatient and inpatient payer systems. But they said, yes, absolutely, in the nhs and they make that distinction specifically in the English NHS system as a WHO quote, pre closure glove change may reduce costs and release meaningful capacity for both local maternity services and the NHS as a whole. End quote. So they're like, yep, why not? This is easy to do. It seems to be cost effective in the NHS system using a higher benchmark of infection within 30 days of 15%, which is kind of not what we see in general in the United States. Okay, so remember, right now we're still on the. On the defense side. We're still trying to defend changing your gloves at C section and showing you that there is data, because the truth is there is. But it's meh quality, it's got some limitations. And even a systematic review says, we probably need more studies that confirm this before it's clinically adoptable. And even the NHS cost effectiveness study said, yeah, but this is probably going to show some benefit, probably only in our market because of the assumptions that we've made for this math calculation. All right, fascinating stuff. So to the senior resident in OB GYN who reached out, is there data? Absolutely. But having data is different than having universally adoptable data. Because again, just because the systematic review and meta analysis was done, you have to take a look at the source of bias in these studies. And according to these authors, the amount of bias was kind of considerable. So not only was the overall numbers not that impressive, but the risk of bias within these publications was also pretty high. So this is why these are limitations of using it, that we're not sure if this should be adopted or not. Even though it's low cost, even though it's zero risk and it may potentially help. So let's stop there. That's in the section that is saying, yes, it's fair to do it. And now let's go back. Now let's switch gears a little bit and we're going to get into the. The group that says, wait a minute. Before you do this universally, thank you very much. Before you do this universally, maybe we need better data and that's why it's not in the systematic reviews. All right, all right. Okay, no more. No more gavel banging. Okay, One more time. I think it's kind of neat, Michael. Thank you. That was a little delayed, but I'm gonna let that slide. So now let's put the plaintiff. Let's take the hat of the plaintiff to go. No, you don't have enough data. We're not doing this. You suck. All right, probably not. That was kind of aggressive. Let's take away the you suck part and Just go. Yeah, I appreciate your data hat nod to you, but we're not going to adopt this. So currently, acog, SMFM and the CDC do not advocate for routine surgical glove change after placental delivery because the current evidence is considered insufficient to support a formal recommendation. Although several randomized controlled trials and meta analyses have suggested this plan as a way to reduce surgical site infection rates. End quote. That was directly out of a commentary. So there you go. So, acog, cdc, even who, guys, and who sometimes says some kind of wacky things. Again, from a global perspective, that's not necessarily adoptable here in the U.S. but even in this case, even the WHO says, hey, look, we reviewed the data, it's intriguing, it's super cheap, and it's zero risk. So if you want to do it, why not? However, the evidence is weak or moderate at best, and therefore is not currently recommended. Remember, that's who figo is like, we need to adopt this. So, so what does this tell us, guys? This is the, the beauty of medicine. At the same time, this is the stuff that irritates people because it would be nice as everything kind of, you know, was on the same page, but sometimes it's not. As I've said, as we led into this after the intro, I have no problem doing this. This isn't going to hurt. Why not? It can possibly help. It's maybe make it part of your little idiosyncrasies that you do at C section. With the data being weak to moderate and needing replication, it's definitely not going to hurt anyone. Right? So if you want to do this. So my answer to this resident was, hey, if they want to do it, why not? And you know what? Do this as a quality assessment. Look at that physician's infection rates after C section and see if that's different than the general other faculty maybe something to consider. So yeah, the short answer is yes, there is data, but at the same time, it's not great data. And so as far as we see it, the judge call on this is it really is a judgment call, no pun intended. So interesting. Erase doesn't talk about this. Who says yes, we realize this is out there, but we're not going to formally recommend it yet. Although medicine changes quickly and maybe in 2026, 2027, this would change gears, but as of right now, we're just not there yet. So again, this is pretty quick, but I just wanted to get this out as a very targeted way. I think we've done what we're supposed to do as we put this issue on trial. Thank you, Michael. You kind of beat me to that a little bit. Hold on a minute. Let me do that again as we put this on trial. Thank you. Last time, you beat me to it. All right, so yes, yes, there is data. If you want to do it, knock yourself out. I have no problem with that. Just understand that some of the data is limited. But our motto here on the show, as always, has been, if it's low risk and possibly might could help, why not do it? Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. This was kind of stupid, wasn't it? Not the content, but, Michael, I think let's just stop doing all that, huh? Okay, one more time. Let's do it. Okay, okay. I'm sorry. Podcast family, I promise, back on track. Please don't stop following us for stupidity. All right, this is what we do for doing this on a Sunday when we're kind of beat and kind of loopy. Podcast family, we'll see you on another episode of the no Spin podcast. Now that we've done all that, Michael, please, for the love of almighty God, let's take it home. This has been Dr. Chapa Zobi Gyn, no Spin podcast. Podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast.