← Dr. Chapa’s OBGYN Clinical Pearls 
Dr. Chapa’s OBGYN Clinical Pearls
“New” Data: CS Skin Incision To Delivery Interval (AJOG-MFM)
00:20:25
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If you do obstetrics, you know that things that we do in OB are on a timer. The NST has to be 20 minutes. Biophysical profile is 30 minutes. The one hour glucola is hello in one hour. So why don't we infect other times. Now we take times in the or, we do time of skin incision, we do uterine incision and time of fetal delivery but don't really enforce like a certain time limit. Even though a recent publication From January of 2026 that we covered on this show talked about the importance of looking at the uterine incision to fetal delivery interval. That's important because once you incise the uterus there's pressure shifts from the placenta that change. There's blood loss of course. And there a direct correlation between uterine incision and fetal delivery time. We covered that. That's the BART publication from the gray journal in 2026. Now embedded in the skin incision to fetal delivery time is that uterine incision to delivery time. Right. So it's a broader box called skin incision to fetal delivery that is the subject of a new publication that just came out ahead of print. It's not even officially out yet in the Pink Journal that is a mfm the Pink Journal that was released as an article in Press on June 17, 2026 that is out of the Bronx in Montevior Albert Einstein College of Medicine. I've got great friends there. So they're looking at a broader box here, skin incision to fetal delivery. Now, as we just stated, it's important how long it takes when the uterus is open to get the child out. In the BART publication, which we will remind ourselves of in this quick episode, the longer that you take to get the child out once the uterus is open, that matters. Every minute is an increased risk of metabolic acidosis. However, let me just spoil it here. When you plug that into a broader box of skin incision to fetal delivery, you may not find a significant difference based on whether you're quicker or later because it gets diluted in the bigger box. Does that make sense? So that's one of the differences here. Even though we covered uterine incision to fetal delivery, which is embedded in the larger box of skin incision to fetal delivery, the results here are very different from bart. So the BART publication said, hey, once you enter the uterus, get out quickly. This new retrospective study from the Bronx said, hey, you know, we really didn't find that big of a deal from incision to fetal delivery. It's a very modest, very small effect. Maybe some increased risk of nicu, but there was no change in metabolic acidosis. So how are those stones different when the uterine incision to fetal delivery time is embedded within the bigger box of skin incision to fetal delivery time? And the answer is twofold. One, it can dilute out if you include into a bigger picture. And then the second is the types of C sections that were studied. When BART did the uterine incision to fetal delivery publication, it was in non urgent term sections. Non urgent meaning everything but category one C section. Now I don't mean category one is a fetal strip. I mean category one in terms of a type of C section, which is A stat. Remember those? We'll talk about that after the intro. There's category one stat, two urgent, three is necessary but not urgent, and then four is elective. So the Bartch publication that looked at uterine incision to fetal delivery was in non urgent term sections. This new publication looked at the broader box of of skin incision to fetal delivery in all classes of C section 1, 2, 3 and 4, which diluted the result. So let me just prepare you. When somebody tells you we can take our time, don't worry about it, it's fine. A new publication from the Pink Journal said, nah, it's just maybe a modest increase. The odds ratios were really small. Not a big deal. Take your time. That can be true from skin to uterus, but from Uterus to, to fetal delivery, it definitely matters. This is why you got to know all the data guys. Because just reading this publication from Monte Fior which says, you know what, really, that wasn't big of a deal between the shorter skin to fetal delivery and the longer. There really was no change in metabolic acidosis, maybe a little bump in NICU in those who took a little bit longer, but it was very, very slight risk. So don't worry about it. That's not the deal at all. When you take a look at a sub analysis, which they should have done, looked at specifically the uterine to fetal delivery, it would have been interesting if they would have found the same thing that Bart found. So again, these are two retrospective studies, two different locations, but are looking at different things. One is looking at the very precise uterine incision to fetal delivery. That is Bart from the Gray Journal, which we talked about in January that found time matters, don't mess around, get that child out when the uterus is open. And then the broader skin incision of fetal delivery, that gets kind of muddied. And we're going to go over that publication. So it really should be two different boxes here, not one, because they're very different. It should be skin to the uterine level and then uterine level to the child. Without doubt, uterine level to the child is a big deal. The question is, is it the same deal when you're, when you're talking about skin incision to fetal delivery and is probably no. So that's where we're going in this episode. Brand new study coming out in the pink journal from Monte Fior on skin incision to fetal delivery. 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. In the US there's this kind of prime time media show news recap called 60 Minutes. And I was unaware that my intro sounded like 60 Minutes. You know, the little stopwatch at the beginning on today's 60 Minutes. Not a sponsor and not affiliated with 60 Minutes. All right, stop that. Okay. Now that we covered that and made that disclosure. So this study. Yeah, interesting. Again, hasn't officially come out yet. The title of which, again, this is in the pink journal. The title is Skin Incision to Delivery Interval and Neonatal Outcomes. A Retrospective Cohort Study. Right to the point. Nothing shiny and you know, trying to impress anybody. Tells you exactly what it is. From ajog mfm. Two big Differences here on this publication. Remember that BART that we covered in January used non urgent term deliveries. This one used all kinds of C sections. 1, 2, 3, 4. And the BART study, again, smaller snip at a time, uterine incision to fetal delivery. And then this publication used the broader context of skin incision to fetal delivery. Found different things, guys, different things. Now we track all these times in the OR skin incision. Okay? Uterine incision. Yes. Fetal delivery. Okay, we track them and. But they're not enforced. Like, hey, guys, you've been trying to get, getting the kid out for like 10 minutes, maybe tee the uterus or do something. I mean, that would be awful. 10 minutes of uterine incision, not getting the kid out will be a long time. So we have to, we're going to track it, which is good to do, but the reason we track it is because it's potentially linked to some issues. Now, be very clear, this is one of the issues when you're looking at skin incision to fetal delivery, because the biggest variable in there, guys, the biggest issue is how long that uterus is open and blocked. Again, that's the BART publication. We will summarize those findings in a moment. But that matters. However, assuming that the placenta has normal blood flow, assuming it's not a stat, all right, that's a different issue. But in general, in kind of a routine section, the time from the skin to the uterus, as long as the patient's on a tilt and the baby's condition is fine, really shouldn't matter. That's what most of the data has found. All right? And that's exactly what this data found. Because even though there's maybe a small increase in the rate of NICU admissions for those who took a little bit longer, longer, there was no difference in metabolic acidosis. So they went to the unit for something else. But it's not metabolic acidosis. Okay? So that's something important to note, and I'm gonna tell you that here in a minute. So the two big differences are that this study that came out June 17, 2026, looked at the bigger box and included all kinds of sections. That's not me making it up. It's right there in the publication. Let me read it. The primary exposure was incision to delivery interval and defined as a time in minutes from skin incision to delivery, and the primary outcome was NICU admissions. Here it is. Quote, Cesarean urgency was characterized using the National Health Service four category classification system, end quote. One, being stat, two, urgent, three, necessary but not Urgent and then four being completely elective. So it wasn't in non urgent deliveries only like the BART publication. Again, those are the differences here. That's why they got different results. In total, they got 1145 cesarean deliveries that met inclusion criteria. Okay, so let's call it what it is. Let's just say 1100 ish. Okay, so 1100 ish. Take a look at these numbers. That tells you that those who had it stat were significantly less than what you would think, which was the routine 11.4%. So 11% had an incision to delivery interval less than 5 minutes. That's pretty fast. Whereas 1014 had, which was 88.6% had an incision to delivery Interval greater than than 5 minutes. So let me just say it again. Clearly, from skin incision to getting the kit out, 89% took more than five minutes. Because that's pretty typical. Those that had it under five minutes, it's right there in the publication. It said when you take a look at the indication for those, it was based on fetal indication. In other words, there was some kind of fetal concern. So you chop chop, you moved faster. All right, so 11.4% or 11% had an incision to delivery interval less than five minutes. And the vast majority, I mean 89%, had an incision to delivery greater than five minutes. Again, the biggest indication differences were in those that had a smaller skin incision, fetal delivery interval was because of a fetal indication. That's right there in the publication. Okay, now here's the catch though. In those that had longer skin incision to delivery interval versus those that were less, the mean umbilical artery phase were similar, end quote. It was non statistically significantly different. And the actual numbers weren't different either. So it didn't make a difference. Guys, so you all get this. So whether you did a skin incision to fetal delivery that was less than five minutes or took longer than five minutes, there was no change in umbilical artery ph, no change in metabolic acidosis. That is not what BART found in the gray journal at the start of the year. So that's a big contrast. All right, now why, why again those two differences? Well, number one, it got diluted out. Number two, you're talking about different kinds of sections. This one includes all of them. The other one was only in non urgent term, cesarean sections. Okay, now they go on to say again, back to the pink journal, back to this recent publication. When you do multivariate logistic regression, okay, so you control for different things. Incision Time to delivery interval was associated with increased odds of NICU admission, end quote. So you're like, oh, wait a minute. Well, that's bad. The longer that you take mucking around, the worse it is. Yes, for sure. But look at this odds ratio, guys. The adjusted odds ratio was 1.02. Huh? With a 95% confidence interval of 1.00 to 1.04, end quote. That is really small, guys. So they found basically from skin incision to getting the kid out across all four types of section, not a big deal. There's no change in metabolic acidosis. Maybe a small bump, maybe small bump in NICU admissions, but it's very, very slight. So, yeah, maybe not that big of a deal. Now, not surprisingly, C section categories 3 and 4, which were, you know, necessary but not urgent and then elective, obviously had lower odds of NICU admission compared to category one. Because category one is stat. Those are the true emergencies, that is cord prolapse, acute bleeding, like an acute abruption. You have a bad looking category three strip. I guess they're all bad looking, but a category three, those are all category one C sections. And those are the ones that had lower. They had higher chance of NICU admission, but duh, that just goes by the indication. So nothing here is really mind blowing. I'm doing this as an episode because I don't want people to walk away from this going, take your time, it'll be fine. That tends to be true from skin to uterus, but from uterus to skin, which was diluted out in this publication, guys, don't mess around. That's why before you do a section, here's a big clinical pearl. Know where the kid's orientation is, know what's presenting, have a plan, make sure that kid's cephalic, and even after that patient gets a spinal or general, if that's the indication. Before you cut into the uterus, feel outside the uterus, confirm presentation, make sure that baby's head is down there, do a Leopolds on the uterus and internally so that you have a plan. Because figuring out that an arm is presenting there after you cut low transverse is not the best time to figure that out. All right, podcast family, I'm inviting you to elevate your coffee routine with the strong coffee company that is striving to reach our natural greatness. I use it. It's coffee 2.0. It has protein MCTS for energy and mental clarity and adaptogens. This is one of my favorite coffees. It in regular, black and latte mixes and now you get 20% off when you go through the link in our show Notes. That's right. Just for being a podcast family member, go to strongcoffeecompany.com discount choppa no spinobg for your 20% discount. The link is in our show Notes.
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So it's our protocol whenever residents are with me, we don't take the patient to the back until we confirm with our handheld V scan. Make sure to check the presentation and then before you cut the uterus, you better check where that head is because that will also tell you where to cut and confirm your presentation. It does matter from uterine incision to fetal delivery, and I'll give you that BART summary in a minute. But when you plug that into a broader context and include all kinds of section, then you kind of dilute that out. So I thought this was important to contrast this new publication from the pink to the previous publication from the gray, that both looked at incision intervals, but they are different. This one used the broader one, the other one used the more acute one. From uterine incision to fetal delivery. Does that make Sense, everyone. So very quickly, let me give you this conclusion from this Pink Journal publication. And then I'm going to remind us all very fast, very quickly of the BART study, because that could be problematic if it's lost, and I definitely don't want to lose that importance. So, first of all, back to the key results, as the authors say, from pink quote. In this retrospective cohort, shorter incision to delivery intervals were more frequently observed in higher acuity cases. So let's stop there for a minute. Hey, if it's a stat, you're going to get the kid out faster. Duh. Nothing mind blowing there. And I'm not poking fun at this at all, but that makes sense. That's exactly what you should find. The higher rate of NICU admission in the shorter incision to delivery group in unadjusted analysis likely reflects greater baseline fetal compromise prompting the expedited delivery. Yes, for sure, we get that. Now, here's where they go on multivariate regression. However, although the magnitude of this association was modest. Well, it wasn't modest. It was minimal. But nonetheless, although the association was modest, there was an association with increased odds of NICU admission with longer incision to delivery interval. End quote. All right. Higher rate of going to the nicu. But the important thing is, in their own publication, in their own words, there was no change in metabolic acidosis. So maybe respiratory support or something else. But it wasn't a metabolic acidotic condition, which is the big issue that we fear because that's linked to hie. All right, so very interesting that when I saw this come out in the pink, I'm like, ooh, wait a minute. I wonder how they're going to do this. Because in the Gray Journal, the sister publication, they found that uterine incision to fetal delivery really did matter. But this one, and I knew what they're gonna find when you plug that into the broader, it can dilute out. And that's exactly what happened. Now, very quickly, just as a point of recall, even though we covered this, go back to the, to the archive. Look at January 2026, we covered the Bart et al publication from the Gray. Okay, let me just show you what they found. Very quickly, looking at non urgent term cesarean deliveries, they found that longer uterine incision to delivery intervals independently associated with. With an increased risk of neonatal morbidity. And here it is, guys. Acidemia. Let me give you the two big issues. Dose dependent relationship of about 0.6 percentage points, increase in composite risk for every additional minute. So as a composite risk so just throw everything bad that you can in there and say, here's the outcome per minute that goes up 0.6 percentage points per additional minute. That's the composite outcome. But when you look at specifically the umbilical artery pH, for every minute that increased, there was an increase in 1.5 percentage points of metabolic acidosis. Do you all get this? So for every minute increase after uterus is open, there is a 0.6% increase in composite morbidity and a 1.5% increase in neonatal acidemia risk. And in this publication they termed what was too long. Well, too long was greater than 240 seconds. All right, so less the normal routine is less than 120. Then 120 to 239 was prolonged and excessive was greater than 240 seconds. So if you take too long to get the uterus evacuated from the child, this found that there was a per minute increase in metabolic acidosis and a 0.6% percent increase in overall composite morbidity. Two different publications. So if somebody tells you, I'm trying to give you ammunition, when somebody says, just take your time, you got all the time in the world. Maybe from skin to uterus, but not from uterus to skin. So that's. I, I just. And I wish that these authors from Montefiore would have taken a look at that at sub analysis because that is a big, it's a huge, huge, huge issue here to figure out is if you're going to say skin incision and fetal delivery, there should be two boxes. Skin incision to the uterus and then uterus to the child. Podcast family, as always, we're super thankful for you. We're glad you're part of our podcast community. We've covered something that has not even officially come out yet called Skin incision to Delivery Interval, A Retrospective Cohort Study, and Neonatal Outcomes from the Pink Journal podcast family. Now that we've done all that, let's take it home. This is Dr. Chapa's ob gyn no spin podcast.