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Foreign. It would be a lie if I said, oh, I've never told a resident while doing a C section. Hey, could you move things along a little bit, especially as we're in the process of delivering the child. Okay, now, stat C sections are one thing and a stat. Nobody has time to worry about little small superficial bleeders. We're on a mission to get the child out quickly. But let's say it's a term otherwise elective C section. Yeah, I don't have time for that. I mean, let's still remember our job, which is deliver the child. And there really is something about being precise yet not taking forever to get the job done. 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. Now let me clarify this again. We're not talking about stats. Stats always are quick, you know, in size. Get the child out. That's not really an issue here. I'm talking about the length of time either from decision to delivery interval. That's called the D to D interval. Or let's bring it down a little bit more tighter. So skin incision to delivery interval. Or even a little bit more tighter, a little bit more niche, which is the hysterotomy to delivery interval. That guys, that's the one that we're gonna be focused on in this episode. The hysterotomy to delivery interval. That is also called in the literature the ud, that's uterus to delivery interval. Now, very quickly, yes, it is true. There's been a lot of different pieces of data out in print regarding uterus intervals of timing and neonatal outcome. Now let's start with the big bucket, right? The big one, which is I've decided to do a section and then I actually have the child delivered. That's delivery to decision to delivery interval. Decision to delivery. And the outcomes really do vary based on the kind of C section that we are doing. That's why we have the four kinds of C section classification, right? Type 1 or a Type A. Level 1 C section is an urgent. That's a stat. Like, just think about that, like a level one trauma. That's the height, highest acuity. You've got to have the shortest decision to delivery interval. Then you have a level 2C section which is urgent but not stat. In other words, a pretty bad looking category two that hasn't gotten away. All right, then you have level 3C section which is necessary but not urgent. Like failure to progress. And the number 4C section is the elective schedule, not labor. In other words, the one where decision to delivery, you've got the most laxity. All right. That's why we have the four levels of C section classification. Why? Because it is generally recognized that the decision to delivery interval can impact neonatal outcome based on the severity of why you're doing the section. That's the whole reason we have the 4 level of C section classification. We're not talking about that one. But now as we bring things narrower, then there's been other sets of data that have looked at skin incision to delivery interval, and that has been controversial and conflicting. However, there is data that skin incision to final delivery of the child interval. So skin incision to delivery interval that. That can have adverse neonatal outcomes, at least in the short term, if it is excessive. And excessive in general is defined as like greater than eight minutes. That's a long time. Okay, eight minutes. But again, very controversial because there are a lot of factors into that. Obesity is a big deal. Was a patient in labor, was a child's ega. What's the level of skill of the operator? What's the amount of bleeding that happened before the child was delivered? So there are a lot of variables and is very controversial. Then we get even more niche, which again, is the focus of this episode, which is. All right, we've made the decision. We're not talking about that. We've already cut the skin and we're not talking about that. Now we're at the uterus. The uterine incision to delivery interval. That's the last step before we get the child out. Does that indicate. Does that timeframe matter? Is that an indicator of fetal harm? Now, I know what you're thinking, dude, how long can that take? And you got the uterus open, get the kid out. True, true. And the average time to do that is under two minutes. I'm gonna show you how this study that we're gonna talk about, which is very recent, you broke that down into three different timeframes. So in general, most children should be delivered after the uterus is entered within about two minutes. Okay. That seems to be the norm. However, there are times deeply impacted fetal head or the head is dislodged, and then it goes transverse. I've had that recently. And maybe it could take, you know, three minutes, four minutes or so. And that' going to talk about in this study, guys, that came out in the Gray Journalist, the American Journal of OB GYN on close to the last day of 2025. That was December 30, 2025. The authors looked at the uterine incision, the hysterotomy to delivery interval, and did that matter? They used three different timeframes that we're going to talk about less than two minutes, between two minutes and four minutes, then greater than four minutes. Did that affect neonatal wellness, at least in the short term? Now, what they found. Let me just throw this out here. I'm just going to give you a little snippet, a little freebie, a little appetizer, if you will. This publication from December 2025 found a correlation in the length of time of hysterotomy to child delivery and adverse neonatal outcomes, meaning the longer that it took, potentially more neonatal acidosis in the child. And we'll explain why that's possible and why that's biologically plausible that, that, that, that founding. That that conclusion was found. Okay, so it does make sense in biology, does make sense in physiology. It does make sense anatomically. So in this publication that we're going to cover, that's our focus from the gray journal, end of December 2025, yes, there was a correlation with length of time of hysterotomy to child delivery being worse, obviously over two minutes. Okay. And then really bad over four minutes. However, here's the catch. Here's the catch. Y' all know we just try not to give you one publication because although this gray journal publication said yes, it's important, and I'm not minimizing that. Guys, yes, it is important. We should be factual. We should be deliberate. We should be directed and directive in what we do at surgery and not spend a lot of time, you know, mucking around, get the job done. But while this publication said, yes, it matters, there was another publication that found no association between hysterotomy and delivery intervals. So in this episode, while we're going to highlight The Gray Journals, December 30, 2025, retrospective study, I'm going to give you the full spectrum of data, including other data that had said, yes, they're right. We found that also. And then the rebuttal which says, no, there is no relationship to uterine hysterotomy to delivery outcomes. It doesn't matter. So I'm going to give you both sides of this as we give you the data. At first, it's serve you the data and then play devil's advocate here to give you the opposite side now because the data is controversial and conflicting. And, guys, I'm telling you, the data that I'm going to give you is just from 2025. And as point of reference, we're still in the first part of January 2026. So this did not happen a long time ago. Okay. However, these two different pieces of publication that are very recent here, guys, have two controversial pieces because the data, in fact, isn't very, very conflicting. And because of that, I'm going to give you real world application guys at the end. So before we get done, I'm going to tell us what we should do. When somebody asks you, is there a correlation between hysterotomy time and delivery of the child and adverse neonatal outcomes, does that matter? And the short answer is, it's complicated. It's possible. It makes sense. It's biologically plausible that it does that. However, here's why the data is conflicting. And I'm going to give us real world applications of what to do with this controversial data. Again, we're going to cover material from 2025. Walk down a brief timeline here of the rebuttal that says, no, it actually doesn't matter. I'll give you that data here in a minute. And so I think I've set it up enough, but that's where we're going. We're going to talk about this interesting issue here of the interval between hysterotomy and delivery. Does it matter? I do not suppose. You've got to speed things up. Hurry up. All right, we'll be right back. This is Dr. Chapa's obgyn no spin podcast. Hurry up, hurry up, hurry up. Yep. It's not just about being fast and being sloppy at C section. It's not just about hurrying up to do the procedure. It's about being deliberate, being aware that the mission is to safely and kindly evacuate the tenant from the uterus as quickly as possible. Because intervals, potentially they do matter. And that's the focus of what we're covering here, specifically talking about the uterine incision to delivery interval. Now, one of the issues with this, guys, before we even get into the data, which, by the way, this data again just came out at the end of December 2025, does have ties just down the road from my location because part of the author said from this is from McGovern Medical School at UT Health Houston, along with great researchers in Tel Aviv, Israel. So, you know, we do have a personal connection to this just because it's our neighbor and we've got great friends at UT Houston. So very well done. We need more information on this. But one of the issues with this is that a lot of stuff has already happened. You get to the uterine incision to delivery interval. Yes, that's a very small niche part of the C section. But there are a lot of other stuff that has happened before that. So again, just put things in perspective. And again, very controversial because what I'm give you first is the data from December 2025 that says yes, that matters. The longer that you take mucking around in there, the worst potentially can be for the child. Then I'm going to give you the rebuttal data which says no, there's no difference in outcomes based on uterine inc to delivery interval, the UD interval. So what do we do with that? It's the he said, she said typical story. And at the end of the episode, I'm gonna give us some real world implications. Remember, when the data is on both sides, when the data is dichotomous, our job is to be the referee and say, what do we do with this? I will tell you that. Okay, so first of all, this study from the Gray Journal is retrospective. So just consider that it included all singleton pregnancies that were delivered by non urgent, necessary in delivery and had to be at term. In other words, greater than or equal to 37 weeks. It was a single center patient population base. Now when I say non urgent C section that included both elective and intrapartum, it just couldn't be a stat section. All right, Deliveries that were performed because of concern for fetal or maternal compromise, including non reassuring fetal tracing or failed operative delivery or cord prolapse and abruption babies with big anomalies, anything like that. All of those were excluded. All right, so term singletons, non urgent cesarean delivery, including intrapartum as well as planned elective. So it was close to 5,900 deliveries. So it's a good number. And they looked at three hysterotomy to delivery intervals, three different data sets and they didn't come up with this. This is based on previous data and the average times to get the kid out. All right, so let me just say now the average time from uterine incision to fetal extraction in general is around two minutes. Okay, so at two minutes or below is considered otherwise normal or routine. Now they did this in seconds. So it's 120 seconds. But if you think in seconds, that's great. I think in minutes. So 120 seconds was routine. Too long was greater than four minutes or 240 seconds. And then there was a middle one. Which wasn't routine, wasn't excessive delay. It was longer than normal, called prolonged. All right, so you have three main data sets. Routine, prolonged, and then excessive delay. Routine less than two minutes. Prolonged two to four minutes. Excessive delay more than four minutes. Remember, this is just from the uterine incision to the delivery of the child. Now think about why would that. That would be the case. All right, we understand delays in skin incision to ultimate fetal delivery because there's adhesions, you can't see anything. The obesity gets in the way, and it's hard to retract or use the O ring retractor or whatever. But the difficulty here is, once you're in the uterus, why would it take so long to get the kid out? This is typically, think about it. Potentially deep fetal head impaction. It's the baby's head who is dislodged. It becomes asynclytic and or versus transverse, which I've had, and I think I covered this in a previous episode. We had a case where I was faculty. Baby was deeply head engaged, deep transverse arrest. By the time they dislodged it, baby went transverse. So I scrubbed in, got the feet out, pulled it out, but that still, that incision to delivery interval was about three minutes. Okay, so the point is, something atypical already is going on. If we're talking about a prolonged time because we're in the uterus already, like, why can't we get the kid out? So there's something else going on. And potentially. And here's one of the big flags here, guys, because, remember, this study did find potentially an adverse issue. It's taking too long. But one thing that's hard to stratify for is what? Remember, we're in the uterus, and we're talking about taking a prolonged time to get the kid out, and that's uterine. It's manipulation of the child. Are we pressing hard on the child, which possibly gives a vagal response, releases catecholamines. What are we doing inside the uterus that also can contribute to fetal decompensation or just, you know, lower ph that's not just related to the interval. Does that make sense? So knowing how to do the extraction, recognizing an issue quickly, asking for help quickly, these are all vital. That's why, guys, that's why in every C section, you say urine incision time and then delivery time, because that's one of the things that is tracked or should be tracked worldwide. Okay? And the implication, of course, is that a longer uterine incision to delivery interval means something was going on. And that is the catch. What was going on? And that's one of the flags here that makes just looking at the interval. And meanwhile, the item was like, dude, I'm innocent. It's not me. It's the manipulation going on inside to get the kid out. Do you see that? So that's. That's a big variable here, outside or in addition to the issue of, like, operator skill and technique. Okay, so there's a lot of factors here, and this was retrospective. Nonetheless, we need good data looking at less than two minutes, between two and four minutes, and then greater than four minutes to get the kid out. All right, fine. The short of it was, is that compared with routine delivery, defined as less than two minutes, both prolonged, that's between two and four minutes, and excessive delay greater than four minutes, they were associated with higher risk of composite. So that's to catch a lot of things. Composite neonatal adverse outcomes with an adjusted relative risk of 2.18. Okay, now the catch here is that the 95% confidence interval did touch one. It was 1.28 to 3.7, but still pushing towards a positive association. Okay, so, yes. The short answer is yes. They found that the longer that you take, there is an increased risk, a relative risk of about three. Well, let's call it about three and a half, especially over two minutes and especially, especially over four minutes. Now, here's what else they found. Quote, each additional minute of extraction increased the composite outcome by 0.6 percentage points, end quote. Meaning, again, we shouldn't do things just to be fast and sloppy. Be deliberate, be mindful. If you anticipate an issue, say I needed somebody to put a hand, a gloved hand on in case we need a fetal release because the fetal pillow is having some controversial issues. Just be aware, remember, if it's deeply impacted, something that can help also is putting the patient in a frog leg position versus flat supine so you can access the vagina better. So there's tricks that you can do to try to minimize that. Anticipate a complicated uterine incision to delivery interval. Okay, so they also go on to say, quote, weighted analysis for cord gases demonstrated that an interval greater than four minutes, again, that's pretty long, was associated with an umbilical artery pH. Now, here's the catch, guys. Less than 7.1. All right, that's fine, but we're more interested in 7.0 or less. Okay, so they use again, 7.1, but that's fine. So they did find an issue there with a base deficit of greater than 12. So they said, yes, this is not just an issue of APGAR scores, potential NICU admissions, that this actually dropped the base deficit at a relative risk of like 11, especially after 4 minutes. So short of it is, yes, this mattered. And this relationship was consistent whether the C section was pre labor elective or it was an intrapartum C section. Okay, so short of it is this publication with UT Houston ties as well as Israel found, yes, there is an association between uterine incision and fetal delivery. So be deliberate, don't take forever. Have a plan. If you. If you're struggling at one minute, call for help. Uh, and I'll get into that in the world, real world application implication here in a minute. All right, so there was an association on this study. And that's not the only one. Even though it's retrospective and even though it's hard to stratify, uterine manipulation technique, experience level of the operator, that's. That's just wasn't taken into account. These are all things that can affect this, leading potentially to some observer bias. And that's why, guys, let me just say right here, these very authors say, hey, we found something kind of important. However, let me read this directly. Listen to this quote. Prospective studies are needed to confirm causality and clinical utility, end quote. In other words, they said, we found an association, Guys, we're not saying it's causation because there's a lot of things in there that can happen, like uterine manipulation, operator skill and experience the amount of bleeding at the hysterotomy side. Did you go through the placenta to get the kid out? So there's a lot of factors here that are saying, hey, guys, it's just an association. Be aware, be deliberate, don't take forever. But we probably need prospective studies to confirm causality and clinical utility, end quote. Totally agree. However, even though it is true that we need more studies, they are not the only ones to show this result. Bader et al back in 1990, guys, how about that? 1990 in the green Journal published very similar findings using much smaller cohorts of patients. So he looked at 25 women. Yeah, just 25. It's all right. Undergoing cesarean section under epidural and 28 patients undergoing cesarean under spinal. And he found that infants delivered after a prolonged uterine incision to delivery interval had significantly lower ph values in both the epidural and the spinal groups. So they said, look, yes, there is something here. If you take forever, once you're inside the uterus, potentially you could drop umbilical arterial ph. And that's an issue. And they had this whole discussion. Well, the baby goes under stress is a catecholamine release. It causes vasoconstriction restriction in the child leads to metabolic acidemia. So the short of it is they concluded, quote, the importance of minimizing the uterine incision to delivery interval, regardless of the type of anesthetic selected, has been demonstrated. End quote. Sure, guys, nobody argues that. It makes sense. If you're asked, does it matter how long it takes to get the kid out after you enter the uterine cavity? Of course. However, that varies because of a lot of different factors, including operator skill, the amount of blood loss involved, the amount of manipulation of the child and the pre existing condition, everything else that happened before the point that you got to the uterus. Okay? So it's very hard to single out this little dot in the entire line of care that has happened as a child is getting ready to be born through the hysterotomy. So I've covered the December 2025 retrospective study. There is this 1990, again, that's a long time ago. 1990 Green Journal study that showed. Yeah, we found the exact same thing here. There is a correlation, direct correlation, between uterine incision to delivery interval and adverse neonatal outcomes. However, here we go, guys, hold on. We're almost at the end. However, not everybody agrees. In other words, there are other studies that have showed no association with the UD interval. Okay, so we can go all the way back. We're going walk a little timeline here starting in 2010. 2010, guys, again, 16 years ago, this was looked at in the International Journal of Gynecology and Obstetrics. It was a study of 933 elective term cesareans, all done under regional. All right? And they looked at different intervals. Induction of the anesthetic to delivery, skin to delivery, uterine incision to delivery interval. That's the one that we're talking about. And here's what they found. Doesn't matter. None of those had significant impacts on measured neonatal parameters. So again, we're just. Now we're doing the rebuttal side, guys, that started in 2010. Even though there's others, we got to draw the line somewhere. In 2010, International Journal of Gynecology and Obstetrics, with an N of 933, saying it doesn't matter. We didn't find any correlation. And that's not just U to D, that's skin to D. Skin to delivery interval. That didn't matter either, either. Now, more recently, let's go from 2010 to 2015. The impact of this interval on neonatal outcome was looked at in the American Journal of Perinatology. So now we're walking down the timeline showing the rebuttal evidence. This was out of the Department of Obstetrics and gynecology, out of WashU with names that we all recognize. Methodias Tule, you've got George McCones, great authors, when they were still again at university at Washington University WashU in St Louis. So 2015, American Journal of Perinatology. These were all women undergoing in labor term cesareans. Right. So these are intrapartum. So they already have a little extra stress thrown in there. Okay. And they looked over a two year interval and they wanted to find out if the time in seconds from uterine incision to delivery matters. That's exactly what we're talking about. Short answer, no. Now, they had an n here of 812. Again, respectable. It's a good number. Quote, There was no significant difference in the rate of hypoxic morbidity with increasing increments of 60 seconds from uterine incision to delivery, end quote. All right, so it didn't seem to matter. However, they did find that in those rare situations. So here it is, guys. So here's the. No, it didn't matter, but maybe it did. Okay, so they found both things. No, overall it didn't matter because most deliveries happened under four minutes. However, for those that had the highest quartile uterine incision to delivery interval, defined as four minutes, that's 240 seconds, they tended to have a higher risk of neonatal morbidity. They did have a higher chance of hypoxic morbidity in that subset, but again, that was very rare. So they called that an outlier. And so overall they concluded duration from uterine incision to delivery for in labor cesareans of non anomalous term infants was not associated with an increase in risk of hypoxia associated morbidities. End quote. Just given the rebuttal here. Remember, we're just trying to give everything so we can all consider this. And at the end, which we're about to get to, I'm going to give you real world implications and applications of uterine incision to delivery intervals. So in this study, again, 2015American Journal of Perientology, no association was found. Now let's do the last study, which was in 2023, just two and a half years ago, in comprehensive clinical Medicine. This was a prospective study. The title was A comparison of the effects of time from uterine incision to delivery. Exactly what we're talking about on neonatal outcomes in women with one previous and repeat two or more cesarean sections, end quote. So these are all repeat sections with the assumption that maybe it's going to take longer for those with multiple sections because maybe there's omentum adhesion to the uterine wall or fascial agglutination to it. Whatever. That's the premise. Short answer, none of that mattered now. They looked at umbilical cord ph, lactate base deficiency, rate of obstetric complications, and they were, quote, comparable between the groups. In other words, they found. Let me read this directly. 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. Further studies with larger cohorts are needed to elucidate this issue. End quote. Guys, it's he said, she said. Some things in medicine are perfectly gray and that's okay. The short answer is, as we get ready to wrap this up, I'm going to give us right now, now that we've covered that, yes, it does matter. No, it doesn't matter. Perspectives, real world implications. Because it's not just about being fast and sloppy. It's about being deliberate and purposeful. Hurry up, hurry up. Hurry up. Up, up. Hurry up, Hurry up, Hurry up. Up, up. Hurry up, Hurry up, hurry up, up, up. Hurry up, hurry up. Yep. It's not just about hurry up and get it done. I've had residents come out and they're like, woo, that was 20 minute C section from skin to skin. And I'm like, woo, the counts are off. I will cut you. I mean, it's not about be. Don't go bragging about how fast your C section was. That's, that's, that's not, that's kind of rude. And it doesn't mean that you're skilled because you could be sloppy and fast. I want you to be deliberate and, and purposeful, realizing that times, although controversial, from decision to delivery, skin incision to delivery, uterine incision to delivery, potentially at least biologically plausible, they could have a negative impact on the child. So don't be fast and sloppy, but don't be slow pokey either. Get the job done. The short of it is, as a real world implication, we don't really know if there is a rigid cutoff from uterine incision to delivery that that could potentially hurt the child. Although there is some evidence that prolonged times more than four minutes potentially could result in metabolic acidosis and some temporary adverse issues to the child. But there's a lot of issues here because none of these studies, guys, here it is. None of these that looked at the UD interval prove causality. The truth is this causality is probably partial. There's a lot of other factors that go into play here. And so it's very diffic to just say it's the interval by itself that drops it. There's uterine manipulation, operator scale, all the other conditions that led up to that point. So the real world implication is this, be deliberate, anticipate complication, have help around, especially with a deeply impacted fetal head. If you know that it's going to be difficult to dislodge that. And again, no issues with the SOS pillow, but there is some issues and concern with that. Have somebody who's trained to use a vaginal hand or ideally release, release the shoulders from above once you make the hysterotomy so you can pop that vacuum and get that baby's head clear from the impaction. Okay. In worst case, do a Pywardian maneuver where you deliver the baby in a reverse breach, just even though the baby's head down, grab the feet, invert the baby and delivered breech. I've done that. It's a little tricky, but it is possible. It's called the Pedwardian maneuver. So anticipate. The short answer, guys, is anticipate complication and be thinking on your feet. That's why every section that goes back, especially if it's term elective, it's not intrapartum. We put a, it takes 10 seconds. We have a V scan, a pocket ultrasound probe. It's connected to our phone. And we don't just feel with our hand. We confirmed, hey, that baby is cephalic. So at least we know where the placenta is and where the baby's head is to try to minimize the uterine incision into delivery interval. So, short answer, does it matter how long it takes to get the kit out after you've entered the uterus? Possibly. It makes sense, but so does all of the manipulation that's done to affect that delivery. So although controversial, it does make sense to be as deliberate and purposeful as possible to minimize the UD interval in the safest way possible. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. We have summarized a brand new study that just came out on December 30, 2025, ahead of PR print in the Gray Journal. And now that we've done all that, can we take this home? Michael Yep. All right. Well, we'll see you next time. Podcast family. Let's take it home. This has been Dr. Chapa Zobe 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. It.