Dr. Chapa’s Clinical Pearls: Surprising C-Section Data

Podcast: Dr. Chapa’s Clinical Pearls
Date: September 28, 2025
Episode Theme:
This episode explores new, “surprising” findings about cesarean sections (C-sections), specifically looking at the differences between C-sections performed during labor (intrapartum) versus when the patient is not in labor, and highlights the issue of intraoperative pain experiences during C-section, including psychological sequelae like PTSD. Dr. Chapa draws on two recent publications (Sept 2025, AJ Perinatology and Aug 2025, AJOG “Gray Journal”) and personal clinical experience to deliver relevant, evidence-based pearls for medical students, residents, and practicing healthcare providers.

Main Discussion Points & Key Insights

1. Shakespeare, Macbeth, and the Historical C-Section Reference

• [01:09] Dr. Chapa begins with a memorable pop culture tie-in—referencing Shakespeare’s Macbeth, in which Macduff claims to have been “from his mother’s womb untimely ripped”—noting this is an early literary reference to C-section.
  • Quote: “I would like to think I’m not untimely ripping any child from a mother’s womb...” – Dr. Chapa [02:24]
• Sets the tone for the episode’s blend of history, evidence, and practical clinical guidance.

2. Clinical Vignette: Conservative Management in Labor

• [03:25] Dr. Chapa recounts a recent case (from that morning), illustrating conservative labor management:
  • Patient in spontaneous labor with frequent contractions and late fetal heart decelerations.
  • Rather than rushing to a C-section, Dr. Chapa advises intrauterine resuscitation (terbutaline, IV fluids, repositioning).
  • Successful vaginal delivery follows.
  • Point: Emphasizes fighting for vaginal birth when appropriate, balancing vigilance and restraint.
  • Quote: “Let’s fight for a vaginal delivery here. I mean, it’s only been about …15 minutes of lates. So it’s still actionable.” – Dr. Chapa [06:23]
  • Pearl: Regret often follows “the C-section you don’t do”—suggesting missing indications is riskier than acting conservatively, but highlights new data that challenges this mindset.

3. Surprising C-Section Data Part 1: Intrapartum vs. Elective C-Section and Placenta Accreta Spectrum (PAS)

Key Study 1: “Impact of Labor in Primary Cesarean Delivery on Subsequent Risk of Placenta Accreta” (AJ Perinatology, Sept 2025)

• [10:29] Does C-section timing (in labor vs. not in labor) change the risk of abnormal placental attachment in future pregnancies?
  • Classic knowledge: Any C-section raises placenta previa/accreta risk.
  • New finding: Primary C-section during labor raises the chance of a placenta accreta spectrum disorder by six-fold compared to a non-laboring C-section.
    • Quote: “Primary cesarean delivery during labor increased the chance of having a placenta accreta spectrum disorder six-fold… which is something that we really didn’t know before.” – Dr. Chapa [17:16]
  • Adjusted risk ratio: 6.3 (CI: 1.7–23.3)—not just confounded by other risk factors.
    • Quote: “Even when you control for those things…a labored compared to non-labored primary cesarean delivery, the risk ratio…the chance…was different. This is crazy.” – Dr. Chapa [18:19]
  • Pearl: The indication/timing of a first C-section seems to matter for future PAS risk—not just the number of C-sections.
  • Clinical take-home: Do not rush to C-section unless necessary; avoid “willy nilly” decisions, as timing influences future maternal morbidity.
• Surprising aspect: The magnitude of increased risk for PAS after an intrapartum C-section had not been fully appreciated.
  • “Everything has its risks and benefits…not to scare you…if a patient needs it, but…take into account the timing.” – Dr. Chapa [19:44]

4. Surprising C-Section Data Part 2: Pain During Cesarean Delivery & the Patient Experience

Key Study 2: “I Feel Pain, Not Pressure” (AJOG/Gray Journal, Aug 2025, by Rachel Summerstein)

• [12:37] Dr. Chapa’s wife (an EMDR/PTSD therapist) highlights this patient-written, data-driven article exposing under-recognized pain during C-section.
  • Journalist/author had a traumatic intrapartum C-section; her reports of pain were dismissed as ‘just pressure’ despite her clear verbalizations.
    • Quote: “She kept telling them, ‘I feel pain.’ And they said, ‘It's just pressure, you're fine’…She was moving her legs and saying ‘I have pain.’ So be aware of this.” – Dr. Chapa [14:40]
  • Most intraoperative (cesarean) pain occurs with “topped-off epidurals” (not spinals).
    • Top-off epidurals commonly used for urgent intrapartum C-sections.
    • Pain is variable: underreported if not specifically asked, rates range 1.4%–36% depending on definition and survey methods.
      • “That’s a third, guys. 36% of surgical births stated they had some kind of quote, unquote pain.” – Dr. Chapa [22:29]
  • Importance of not dismissing patient-reported intraop pain; confusion between ‘pressure’ (normal) and ‘pain’ (pathological).
  • Pearl: If a patient says it hurts—listen, assess, and escalate anesthesia as needed; failure to address real pain can lead to lasting PTSD.
    • “Give patient awareness, respect, give patient attention to what’s going on…And if there is stated pain, then do something about it.” – Dr. Chapa [23:02]
    • Interventions: Additional IV agents, local infiltration, possible conversion to general anesthesia.

5. Implications for Practice & Quality Improvement

• Early and honest communication with patients about sensations expected during C-section.
• Proactive intraoperative vigilance (“talk to the patient when she’s under neuraxial anesthesia, as we all should. Make sure she’s okay as we’re doing the procedure.” [25:44])
• Postoperative debrief and pain inquiry can reduce PTSD and negative psychosocial sequelae.
• Quote: “Early intervention decreases the chance of PTSD and internalization.” [22:49]
• Opportunity for research: post-C-section patient pain surveys as QI or resident/fellow research projects.

Notable Quotes & Memorable Moments

• “Let’s fight for a vaginal delivery…Let’s fight for this. And she got a vaginal birth. So the point is we’ve got to fight for it at the same time, not ignore big warning signs.” – Dr. Chapa [06:23]
• “There is a C-section you’re going to regret…That’s the one you don’t do.” (paraphrasing his mentors) – Dr. Chapa [07:05]
• “Primary cesarean delivery during labor increased the chance of having a placenta accreta spectrum disorder six-fold…which is something we really didn’t know before.” – Dr. Chapa [17:16]
• “She kept telling them, ‘I feel pain’…And they said, ‘It's just pressure, you’re fine’…She was moving her legs and saying ‘I have pain.’ So be aware of this.” – Dr. Chapa [14:40]
• “That’s a third, guys. 36% of surgical births stated they had some kind of quote, unquote pain. And that’s the catch. What do you define as pain?” – Dr. Chapa [22:29]
• “Don’t ignore a C-section because the relative risk is…6.3. But…it’s something that we need to take into account. Remember that C-sections, all of them, but especially those intrapartum, potentially carry a risk…in the subsequent pregnancy.” – Dr. Chapa [20:26]
• “Give patient awareness, respect, give patient attention to what’s going on in listening to the patient. That’s it. And if there is stated pain, then do something about it.” – Dr. Chapa [23:02]

Timestamps for Key Segments

• 00:00–02:24 — Macbeth and the C-section: Literary and historical reference
• 03:25–07:36 — Clinical vignette: Conservative labor management and C-section philosophy
• 10:29–19:44 — Study 1 discussion: Intrapartum vs. elective C-section and PAS risk
• 12:37–23:58 — Study 2 discussion: Pain during C-section, topped-off epidurals, and PTSD implications
• 22:29–25:44 — Practice implications: Communication, QI ideas, and summary pearls

Summary: Dr. Chapa’s Major Takeaways

• Do not rush to intrapartum C-section unless clearly indicated—timing impacts future placenta accreta risk.
• Listen to your patient during C-section; acknowledge pain, distinguish from pressure, and act to avoid psychological sequelae.
• Communicate expectations up front, check frequently, and follow up postoperatively to improve both medical and emotional outcomes.
• Stay evidence-based, vigilant, and compassionate in all aspects of perinatal care.

This episode provides actionable, evidence-based pearls for providers and trainees, highlighting nuanced, emerging C-section research and the importance of patient-centered, trauma-aware care.