Podcast Summary: Dr. Chapa’s Clinical Pearls

Episode: Decidua or No Decidua at CS Closure: "New" Sept 2025 Data
Date: September 6, 2025
Host: Dr. Chapa

Main Theme and Purpose

This episode is dedicated to the latest evidence and recommendations on whether the decidual (innermost) layer should be included or excluded when closing the uterine incision during cesarean section (CS), focusing on a just-published (September 2025) systematic review and meta-analysis from the Green Journal. Dr. Chapa compares these new findings to his own episode from 2023 on “decidua-free closure,” offering practical, clinically relevant guidance for residents, students, and OB/GYN practitioners.

Key Discussion Points and Insights

1. Setting the Scene: Revisiting Past Predictions

Timestamps: 00:30–04:00

• Dr. Chapa reflects on his 2023 episode, in which he advocated for decidua-free uterine closure techniques, anticipating future evidence to support this approach.
• A new systematic review and meta-analysis, “Not Closing Compared with Closing the Endometrial Layer during Cesarean Delivery,” was just published, echoing his prior recommendations.
• Clarifies terminological confusion: “In a gravid (pregnant) uterus, the innermost layer is the decidua, not the endometrium.”

  “One of my pet peeves is that in a gravid uterus... there is no endometrium... it has a decidua.” (04:13 – Dr. Chapa)

2. Historical Evidence and Clinical Rationale

Timestamps: 04:01–09:35

• Recapitulation of earlier evidence, particularly the work of Emmanuel Bugeaud and Stephanie Robert (Canada) on uterine closure technique variations (single-layer, two-layer, decidua-free, full-thickness).
• Invitation to review prior episodes for more on closure technique history and RCT data.
• Clinical rationale:
  • Through-and-through closure (including decidua) may introduce endometrial tissue into the uterine wall, predisposing to “niche defects” (isthmocele) and gynecological sequelae such as intermenstrual bleeding and possibly infertility or pelvic pain.
• Clarifies that evidence tying closure technique to TOLAC/uterine rupture is unclear (“cloudy” data), and gynecologic outcomes are the more relevant concern.

3. The September 2025 Systematic Review: What’s New?

Timestamps: 09:36–13:15

• The review included six RCTs (total N ≈ 5,000), directly comparing closure with and without the endometrial (decidual) layer.
• Key findings:
  • Not including the endometrium/decidua in uterine closure:
    • Reduces risk of intermenstrual bleeding (Relative Risk [RR] 0.5)
    • Reduces risk of uterine scar defect (isthmocele; RR 0.53)

  “If it's going to prevent intermenstrual spotting, which is a quality of life issue for a lot of women, then let's do that.” (12:38 – Dr. Chapa)

  • No significant difference for:
    • Heavy menstrual bleeding
    • Dysmenorrhea
    • Pelvic pain
    • Postpartum endometritis
    • Myometrial thickness (Evidence rated as low or very low certainty)
  • No evidence that excluding the decidua is harmful

  “None of the trials found that avoiding the decidua was harmful.” (13:02 – Dr. Chapa)

4. Clinical Take-Home: What Should You Do?

Timestamps: 13:16–16:35

• Practical recommendation for board exams/oral boards:

  “The answer should be... avoiding the decidua, which actually has no structural integrity to begin with... seems to reduce some gynecological issues, which is at least intramenstrual bleeding and... the isthmocele or the C section scar defect.” (13:27 – Dr. Chapa)

• Recap of the systematic review’s conclusion:
  • “Not suturing the endometrium reduces the risk of intramenstrual bleeding and uterine scar defect after cesarean section.”
• Importantly, data on TOLAC, VBAC success, or uterine rupture are:
  • Unclear and confounded by many factors (infection, type of closure, augmentation, polyhydramnios, etc.)
  • No current guidance to select TOLAC candidates based on whether decidua was included in closure.
  • Decision on TOLAC is based on uterine incision location, not closure style.

5. Context, Caveats, and Callbacks

Timestamps: 16:36–End

• Dr. Chapa underscores that many findings in ob/gyn “aren’t new,” but his podcast aims to keep listeners ahead of upcoming publications.
• Reaffirms there is no documented harm to excluding the decidua; in contrast, inclusion increases certain gynecologic risks.
• For those wanting more on single- versus two-layer closure, Dr. Chapa points to multiple prior episodes.
• Signs off with his signature humor and “no spin” commitment to clinically relevant updates.

Notable Quotes & Memorable Moments

• On Terminology:

  “In a gravid uterus... the endometrium becomes decidualized. So really, I would have loved it a little bit better if the title would have been ‘Not Closing Compared with Closing the Decidual Layer.’” (04:38 – Dr. Chapa)

• On Practical Guidance:

  “What is the take home from this brand new systematic review and meta analysis... Don’t include the decidua. Hello. We said that two years ago.” (16:20 – Dr. Chapa)

• On Evidence Strength:

  “The final analysis was using 6 RCTs with a total N just under 5. 6 RCTs. It's good, it's great, but it's not like we're talking, you know, a dozen or, you know, 20 or 36 RCTs.” (10:55 – Dr. Chapa)

• On Harm:

  “No study, no publication showed that there was harm by avoiding the decidua at hysterectomy closure. So this is good news.” (17:30 – Dr. Chapa)

• Signature Humor/Podcast Identity:

  “We're not trying to toot our own horn here. We're just trying to let you know the advantages of being part of our podcast family.” (18:01 – Dr. Chapa)

Timeline of Key Segments

| Timestamp | Segment/Point | |-------------|------------------------------------------------| | 00:30–04:00 | Setting up the 2023 vs. new 2025 evidence | | 04:01–09:35 | Closure technique history and rationale | | 09:36–13:15 | Details and findings from 2025 meta-analysis | | 13:16–16:35 | Practical take-aways, TOLAC/VBAC discussion | | 16:36–End | Recap, clinical caveats, and final advice |

Summary Table: Evidence & Recommendations

| Issue | Effect of Decidua-Free Closure | Certainty | |------------------------------|-------------------------------------------------|---------------| | Intermenstrual Bleeding | Decreased (RR ~0.5) | Moderate | | Uterine Scar Defect | Decreased (RR ~0.53) | Moderate | | Heavy Menstrual Bleeding | No difference | Low/Very Low | | Dysmenorrhea | No difference | Low/Very Low | | Pelvic Pain | No difference | Low/Very Low | | Surgical Complications | No increase/harm detected | Moderate | | TOLAC/VBAC/Rupture | No clear evidence; not a basis for decision | N/A |

Clinical Pearl

• Dr. Chapa’s Clinical Pearl:
  Don’t close the decidual layer during cesarean hysterectomy closure. It reduces intermenstrual bleeding and niche (isthmocele) formation, with no proven harm. There’s no compelling evidence regarding TOLAC/VBAC outcomes—decisions here should focus on incision location, not closure method.

For more depth on closure technique nuances (single vs. double-layer), refer to previous episodes in the Dr. Chapa archives.