Circumventing Previa at Hysterotomy Creation (Surgeon’s Corner)

Summary

Podcast Summary: Dr. Chapa’s OBGYN Clinical Pearls

Episode: Circumventing Previa at Hysterotomy Creation (Surgeon’s Corner)
Release Date: July 3, 2026
Host: Dr. Chapa
Guest/Contributor: Michael

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Overview

In this concise, clinically-focused episode, Dr. Chapa explores pragmatic surgical strategies for performing a low transverse hysterotomy in patients with anterior placenta previa—specifically, how to avoid transecting the placenta during cesarean section. Drawing on an upcoming "Surgeon's Corner" piece from the American Journal of OBGYN (the “Gray Journal”) and reaffirming longstanding best practices, Dr. Chapa underscores the importance of preoperative planning and a meticulous surgical approach for better maternal-fetal outcomes. This episode is tailored to medical students, OB/GYN residents, and practicing clinicians preparing for oral boards or facing real-world surgical challenges.

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Key Discussion Points & Insights

1. Main Clinical Scenario ([01:03]–[03:03])

• The episode examines cesarean delivery for anterior placenta previa in the absence of placenta accreta.
• Key Clinical Question:
  Should the surgeon cut through the placenta or go around it during the uterine incision?

2. Evidence & Rationale ([03:03]–[05:03])

• Dr. Chapa cites new recommendations from the Gray Journal and reiterates consensus from a 2015 FIGO publication (“nothing is new under the sun”)—the safest method is to avoid transecting the placenta.
• The principle is supported by evidence that going through the placenta increases the risk of fetal blood loss and disrupts utero-placental blood flow, potentially leading to worse outcomes.
• Notable Quote:

  "Ideally you do not want to go through the placenta itself. It's a great way to disturb utero-fetal blood flow, especially as you go through the fetal surface..."
  —Dr. Chapa ([03:17])

3. Technique—Surgical Steps ([05:50]–[08:50])

• Step-by-Step Summary from “Surgeon’s Corner”:
  • Perform a standard low transverse segmental hysterotomy.
  • Place the incision only through the myometrium to avoid placenta injury ("cut, aspirate, suction, cut, suction, cut").
  • Stop immediately on visualizing the placenta (cotyledons).
  • Use manual spreading to widen the incision without cutting further.
  • Conduct a controlled manual separation (marginal abruption) at the edge of the placenta, directed according to preoperative mapping.
  • Fold the placental edge down and access the amniotic sac for routine fetal extraction.
• Clinical Pearls:
  • Delayed cord clamping can still be considered if bleeding is controlled.
  • Adapt your technique if active bleeding is encountered; prioritize neonatal safety.
• Notable Quote:

  "It sounds very complicated. It's not, guys. Low transverse. That edge is going to pop out. I tend to fold that downward and away..."
  —Dr. Chapa ([08:05])

4. Reinforcing the Key Message ([05:00]–[09:12])

• Dr. Chapa and Michael repeatedly emphasize:
  • Always go around, not through, the placenta in cases of non-accreta anterior previa.
• Real-world wisdom:
  • Know placental location—preoperative ultrasound mapping is critical to surgical planning.
  • These best practices are high-yield for board exams and clinical safety.
• Notable Quote:

  "If you're asked on the oral boards with an anterior non-adherent placenta, do you go through the placenta or do you go around it? The answer is always, if possible, to go around."
  —Dr. Chapa ([09:12])

5. Contextual Takeaways

• The outlined approach is based on established evidence (2015 FIGO/International Journal of Gynecology and Obstetrics) and reinforced by the latest "Surgeon's Corner" article (2026).
• These surgical pearls help reduce morbidity and optimize fetal outcomes in cesarean deliveries complicated by anterior placenta previa.

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Memorable Moments & Quotes

• "Go around, go around."
  —Michael (recurring, [03:14], [05:00], [05:47], [09:09])
  (Becomes the episode’s catchphrase for the safer surgical approach)

• "You never go through the placenta. Yeah, you go around, go around, go around."
  —Dr. Chapa ([03:54])

• "Try not to go through the placenta itself, which leads to more bleeding and more morbidity. You always go around the edge of the placenta for fetal safety."
  —Dr. Chapa ([08:50])

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Timestamps for Important Segments

| Time | Segment | |-----------|------------------------------------------------------------------| | 01:03 | Setting the surgical scenario; importance of planning | | 03:03 | Reviewing Gray Journal publication; Go through vs. go around | | 05:00 | Evidence from 2015 FIGO publication; “Nothing is new...” | | 05:50 | Step-by-step surgical technique for avoiding placental injury | | 08:50 | Pearls on cord clamping and bleeding management | | 09:12 | Rapid-fire reviewing the board answer: "Go around" |

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Clinical Pearls & Summary

• Always map the placenta preoperatively; plan the uterine incision to avoid placental transection.
• If confronted with anterior placenta previa (without accreta spectrum disorder) during cesarean, create the hysterotomy by going around the placental edge, not through it.
• This approach reduces the risk of fetal blood loss and improves neonatal outcomes.
• The technique remains unchanged for over a decade, now reaffirmed in current literature and high-yield for oral boards.
• “Go around, go around!”—the mantra to remember.

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This episode distills high-yield, evidence-based surgical wisdom into a memorable and practical lesson—a must-listen (or must-read!) for any healthcare provider involved in obstetric surgery.

Transcript

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[Dr. Chapa]

Podcast family. In this episode, which should be very quick and targeted, we're going to cover the best surgical technique to enter through a low transverse hysterotomy when there is an anterior placenta previa. Now, we've touched on this in the past and we've covered parts of this when we've discussed things like the uterine to fetal delivery interval or the larger skin incision to fetal delivery window and how important it is to have a plan before you're at the level of the uterus. That's why it's important to check fetal position to check placental location before you go back to the or. But this is coming out in the Gray Journal in the Surgeon's Corner. Remember, that's one of the little buckets or divisions of the Gray Journal, the American Journal of obgyn and in the Surgeon's Corner. The title of this new publication is how how to Avoid Placental Transection during Low Transverse Cesarean Delivery for Anterior Placenta Previa. This isn't a randomized trial. It's not a prospective study. It's not a retrospective study. It's a surgeon's corner. It's basically tips and tricks of how to navigate complicated delivery situations, even though sometimes in the surgeon's corner they do tackle some gynecological issues and kind of and some hysterectomy cases. But this one, coming out in July, has to do with cesarean section and an anterior previa. So remember, basically, we got two options here. And just by the way, we're not talking about placenta accreta, we're just talking about placenta previa. All right, so we don't suspect that there is an accreta. That's a different issue. There's an accreta. You want to go in the superior portion of the uterus, like in a classical, to not disturb any of the aberrant vessels at the point of abnormal attachment. Okay, so this is a normal placenta previa and a low transverse hysterotomy. Two ways to tackle this. You either go right through the placenta, or you cut up to the level of the placenta, make a marginal abruption, a marginal placental separation, and do an extraction around that. So do you go through the placenta or do you go around?

[Michael]

Go around, go around.

[Dr. Chapa]

Yep. We've covered this before because ideally you do not want to go through through the placenta itself. It's a great way to disturb utero fetal blood flow, especially as you go through the fetal surface of the placenta. So if you're ever asked, and remember, we're doing this at the end of June, early July 2026. So if you're getting ready to do your oral boards coming up in the fall, and you're asked if you have a non accretive spectrum anterior placenta previa, do you go through the placenta or do you go around?

[Michael]

Go around, go around.

[Dr. Chapa]

And just to prove that nothing is new, even though this is coming out in July of 2026, I'm going to give you an older publication that comes out of Figo that basically said the same thing. And that publication, by the way, is not new. That came out several years ago in the International Journal of Obstetrics and Gynecology. That is Figo's publication that actually came out 10 years ago in 2015. So we're gonna talk about the best. Enter the uterine cavity with an anterior placenta previa through a low transverse hysterotomy. And if you can't figure it out from the little snippets that we've been playing, you never go through the placenta. Yeah, you go around, go around, go around. I think I've set it up enough. We'll be right back. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast podcast family. If you can't guess where we're going, even though we've already stated it in the intro, always best to go around that leading edge of the placenta rather than going through it.

[Michael]

Go around, go around.

[Dr. Chapa]

Whenever you go through the placenta, you Destroy the connections, the anastomoses within the placental bed. And so it's a quick way to get pressure differentials away from the child. Plus, if you go through the fetal surface, the of course you're going through actual blood vessels that are connected to the child. So you can lead to blood loss as well. So it's kind of counterintuitive. We want to actually cause minor placental edge separation. That's a minor abruption. That's why it's important to know that it's there before you enter the uterus and work quickly to get around the edge. Just bend the edge either in, mostly it's bent outwards and then go around it as a speed bump to deliver the child around the placental margin.

[Michael]

Go around, go around.

[Dr. Chapa]

So I'm just gonna quickly read you the steps here from the surgeon's corner. Even though it's basically what I've already talked about, but it reflects what was already published in 2015 in a previous publication that looked at two different time periods at their institution. This was a French cohort and the first was actually going through the placenta. And they quickly figured out, let's not do that anymore because it led to, you know, poor outcomes and increased blood loss. And this idea of going around the placental edge that was in the International Journal of Gynecology and Obstetrics. The gynecology is first and that comes through the figo peeps. That was in 2015. And so again, nothing is new under the sun. And this is a, basically a rehash of that now 11 year old data. But it's important and it makes the case this very brief, like three pages long, this brief surgeon's corner about mapping the placenta, mapping the road before you start surgery. So very quickly, let me just read you these steps and then we're going to be done. Remember, we're talking about the non accreta suspected case. So here it is. Quote, perform a standard. That's the catch, a standard. You don't have to go up or into the malmitrim unless you suspect PAs. And then, you know, you definitely don't want to get into issues there with, you know, need for a repeat section. You still want to stay in the low transverse segmental hysterotomy. If you can, quote, perform a standard low transverse segmental hysterotomy. The incision should be placed only through the malmitrium to avoid cutting into the placenta. So cut, aspirate, you know, suction, cut, suction, cut. And then right when you see the cotyledons? That's your. That's your cue to stop at that point, just like you normally do, spread the incision with fingers, you know, cephalad and caudad to make that incision broader, just like you normally do. Then conduct a controlled manual placental separation. And it is an abruption at the placental edge closest to the incision. This maneuver is performed in an anterior encephalad direction towards the closest placental edge identified on the previous placental mapping ultrasound. End quote. So short of it is. It sounds very complicated. It's not. Guys, low transverse. That edge is going to pop out. I tend to fold that downward and away from the. The site of entry. And then as soon as you do, you'll see the amniotic sac. Break the sac and then do fetal delivery over that. And of course, you want to quickly, you know, get on top of bleeding. You can still do delayed cord clamping if the bleeding is contained. If there's a lot of bleeding, then please clamp the cord quickly because the child is still connected. So delayed cord clamping isn't necessarily contraindicated here. It just depends on how much of the placenta you have dissected around in order to get the child out. If bleeding is a concern, it's better to clamp the cord quickly than let the child continue to bleed through the partially detached placental base. All right, so routine fetal extraction afterwards. The whole point we're trying to make here, guys, is try not to go through the placenta itself, which leads to more bleeding and more morbidity. You always go around the edge of the placenta for fetal safety.

[Michael]

Go around, go around.

[Dr. Chapa]

This is coming out once again, podcast family, in July 2026 in the gray surgeon's corner. As a brief reminder, if you're asked on the oral boards with an anterior non adherent placenta, do you go through the placenta or do you go around it? The answer is always, if possible, to go around. Podcast family, this was a quick one. Just a quick tips and tricks on how to get into the uterus with an anterior placenta previa. As always, we're thankful for you. We're glad you're part of our podcast community. And Michael, now that we've done all that, come on, let's take it home.

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[Dr. Chapa]

This is Dr. Chapa's obgyn no spin podcast.