Podcast Summary:

Dr. Chapa’s OBGYN Clinical Pearls – "Does Uterine Incision-to-Delivery Interval Matter?"
Host: Dr. Chapa
Date: January 13, 2026

Episode Overview

In this clinically focused and energetic episode, Dr. Chapa investigates whether the time interval between uterine incision (hysterotomy) and fetal delivery during cesarean section — the "uterine incision-to-delivery interval" (UD interval) — has a significant impact on short-term neonatal outcomes. Using the latest evidence (particularly a study published December 30, 2025), he unpacks both sides of an ongoing clinical controversy and offers practical, real-world guidance for surgeons.

Key Discussion Points and Insights

1. Defining the Issue and Context

• Dr. Chapa frames the episode with real-world scenarios: C-section pacing, urgency in "stat" situations, and the nuances of elective or non-urgent cesareans.
• Main focus: Does the time between making the uterine incision and delivering the baby truly matter for neonatal outcomes, outside of stat/urgent indications?
• Highlights three measurable intervals:
  • Decision-to-delivery (D-to-D) interval
  • Skin incision-to-delivery interval
  • Uterine incision (hysterotomy)-to-delivery interval ("UD" interval) — the episode’s focus

“I do not suppose you’ve got to speed things up because the whole idea of the incision to delivery interval is that prolonged intervals potentially could be worrisome or harmful for the child.” — Dr. Chapa [01:00]

2. Review of New Evidence (Gray Journal Study, December 2025) [08:40]

• Study Design: Retrospective, single-center, term singleton, non-urgent C-sections (excluding stat, abnormal, or complicated cases); N ≈ 5,900.
• Intervals Examined:
  • Routine: < 2 minutes (120 sec)
  • Prolonged: 2-4 minutes (120–240 sec)
  • Excessive delay: > 4 minutes (240+ sec)
• Key Findings:
  • Both prolonged (2–4 min) and excessive (>4 min) UD intervals linked with higher risk of composite adverse neonatal outcomes (Adjusted RR ≈ 2.18; CI 1.28–3.7).
  • Each additional minute increased adverse outcomes by 0.6 percentage points.
  • More pronounced effect if interval >4 minutes, notably with lower umbilical artery pH (<7.1) and higher base deficit (>12).
  • Effect seen regardless of elective or intrapartum indication.

“Each additional minute of extraction increased the composite outcome by 0.6 percentage points.” — Dr. Chapa quoting study [20:55]

• Interpretation:
  • Correlation, not causation. Complexity of cases, operator skill, uterine manipulation, and previous events can all impact the interval.
  • Authors themselves call for prospective studies:
    • “Prospective studies are needed to confirm causality and clinical utility.” — Quoted [23:30]

3. Mechanisms and Real-World Complexities [15:30]

• Delayed extraction often signals underlying complications (impacted/deep fetal head, malposition, technical difficulties).
• Manipulation itself may provoke stress responses in neonate (catecholamines, vagal reaction, metabolic acidemia).
• Recognizing and responding to difficulties promptly (e.g., seeking help or special maneuvers like Pedwardian) is essential.

“Recognizing an issue quickly, asking for help quickly — these are all vital.” — Dr. Chapa [16:20]

4. Historical Data and Supporting Studies [24:40]

• Older literature aligns, e.g.:
  • Bader et al. 1990: Prolonged hysterotomy-to-delivery time linked to lower neonatal pH, regardless of epidural vs. spinal anesthesia.
    • “The importance of minimizing the uterine incision to delivery interval, regardless of the type of anesthetic selected, has been demonstrated.” — Quoted [26:15]

5. Contradictory/Rebuttal Evidence [28:00]

• 2010 Int J Gynecol Obstet (N=933): No significant impact of incision-to-delivery interval on neonatal outcomes in elective terms.
• 2015 Am J Perinatol (WashU, N=812 in-labor caesareans):
  • Overall, no link between UD interval (even up to 4 minutes) and hypoxic morbidity.
  • Exception: Highest quartile (>4 min) showed some increase in morbidity, but these were rare cases/outliers.
• 2023 Comprehensive Clinical Medicine (Prospective, repeat cesarean):
  • No effect of UD interval on neonatal outcomes despite possible adhesions, longer extraction times in repeat sections.

“The findings from this study show that time from uterine incision to delivery has no effect on neonatal outcomes in patients with one previous or two or more cesarean sections.” — Quoted [31:10]

6. Practical and Clinical Takeaways [33:00]

• The “truth” is not clear-cut; both the data and biological plausibility suggest possible risk if extraction is excessively delayed (>4 min), but confounding makes causality uncertain.
• Operator skill, anticipation of difficult extractions (e.g. impacted head), asking for another hand, prepping for maneuvers or changing maternal positioning should be considered.
• Avoid being “fast and sloppy” — the goal is safe, deliberate, and efficient delivery.
• Time intervals (decision-to-delivery, skin-to-delivery, uterine incision-to-delivery) should be monitored, but not at expense of surgical safety or protocol.
• No rigid cutoff for harm is established, but >4 minutes may warrant special attention.

“Don’t be fast and sloppy, but don’t be slow pokey either. Get the job done.” — Dr. Chapa [36:01]

• Tech tip: Use ultrasound to confirm fetal lie/position ahead of elective sections to anticipate challenges.

7. Real-World Implications and Final Advice

• No definitive answer — “It’s complicated.”
• Minimize uterine incision-to-delivery interval when possible, especially if anticipating complications.
• Always strive for a careful and deliberate approach; call for help early.
• Further research needed, ideally prospective and multicenter.

Memorable Quotes & Key Timestamps

• “I do not suppose you’ve got to speed things up because the whole idea of the incision to delivery interval is that prolonged intervals potentially could be worrisome or harmful for the child.”
  — Dr. Chapa [01:00]

• “Each additional minute of extraction increased the composite outcome by 0.6 percentage points.”
  — Dr. Chapa quoting study [20:55]

• “Prospective studies are needed to confirm causality and clinical utility.”
  — Study authors, quoted by Dr. Chapa [23:30]

• “Recognizing an issue quickly, asking for help quickly — these are all vital.”
  — Dr. Chapa [16:20]

• “Don’t be fast and sloppy, but don’t be slow pokey either. Get the job done.”
  — Dr. Chapa [36:01]

Important Segments & Timestamps

• 00:00-04:30: Framing the clinical question; types of C-section intervals and urgency classification
• 08:40-23:30: Main 2025 Gray Journal study breakdown — methods and findings
• 15:30-20:00: Mechanisms for delayed extraction and real-world complexities
• 24:40-27:00: Review of older and supporting literature (Bader et al. 1990)
• 28:00-33:00: Contradictory studies and counterpoints (2010, 2015, 2023)
• 33:00-36:40: Practical advice, real-world implications, conclusion

Conclusion

Dr. Chapa’s take-home: The uterine incision-to-delivery interval might matter, especially when excessively delayed (>4 minutes), but context, surgical skill, anticipation, and intraoperative events are just as important. Evidence is conflicting, so practitioners should strive for efficient and attentive surgery, recognize complexities early, and always be prepared to adapt.

“It does make sense to be as deliberate and purposeful as possible to minimize the UD interval in the safest way possible.” — Dr. Chapa [35:40]

For students, residents, and providers:

• Understand the possible risks but don’t sacrifice care for speed.
• Document all timing intervals.
• Anticipate difficult extractions; work as a team!
• Stay aware of the ongoing debate—ultimately, the safest, most thoughtful pace is best for everyone.