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I'm NFL linebacker T.J. watt, and this is my personal best. YPB by Abercrombie is the activewear I'm always wearing. That's why I reached out to co design their latest drop. I worked with designers to create high performance activewear that holds up to my toughest workouts. Shop YPB by Abercrombie in store, online, and in the app. Because your personal best is greater than any. Let fall thy blade on vulnerable crests. I bear a charmed life which must not yield to one of woman born. Spare thy charms, and let the angel whom thou still hast served tell thee Macduff was from his mother's womb untimely ripped. Oh, y' all remember Macbeth during a. A very dramatic scene. Of course, most of Macbeth is obviously very dramatic, but there's this. There's a scene where Macduff is talking to Macbeth and is like, hey, I'm gonna get you, bro. I'm gonna get you. And Macbeth says, can't do it. I live a charmed life, meaning spiritually protected, like, as if by a spell that he cannot be hurt by anybody born of woman. Now, bo means naturally born, like a vaginal birth. But the guy he's talking to Macduff, who is now his rival, says, ah, not so fast, Macbeth. Because I was not of woman naturally born. I was ripped from my mother's womb in an untimely manner. Y'. All. That's a reference to C section. So McDuff in Shakespeare's play Macbeth is saying, yeah, I can get you, because the witches who kind of hexed you and protected you said, you cannot be harmed by anybody who's born naturally of a woman. Ah, that wasn't me. In other words, I'm going to get you. So, yeah, a nice little C section reference in Macbeth. So why are we talking about this? Well, one is, I thought it was interesting that Shakespeare describes a C section as untimely ripped from his mother's womb. Wow. I mean, untimely ripped. Pretty harsh. I would like to think I'm not untimely ripping any child from a mother's womb, But C section does have some surprising data kind of related to that. So I'm going to explain this here. In this episode. I am. I follow the rules in labor. I'm a very. I practice very conservatively. I really am an advocate for the child as much as for the mother. And, you know, I. I don't want to over call a C section at the same time. I don't want to miss A potential issue. And so this is the conundrum thing most of us have in obstetrics, right? So I am a little, you know, conservative. I don't like a strip, you know, if it doesn't change quickly, then I try to get out. Just this morning, I'm talking about this morning that. We're recording this at around 1am we had to strip. A residents called me. Hey, you can take a look at the strip. Spontaneous labor. She's a grand multiple. She's banging, banging. Contractions away like every two minutes. So she was techies and she was having some lates said, look. How's her pressure? All the vitals are good. I'm like, all right, well, if it's tachycystole, give the baby a break. I mean, give her some turb, give her some IV fluids, put her on her side. Of course, don't give her O2 because she's not hypoxic and let the baby recover. And sure enough, the contraction spaced out to a more functional manner. So she was contracting every three to five minutes. The lates went away with one dose of trine, 250 micrograms sub Q along with the IV fluids. And baby recovered. Boom. All to say, two hours later, baby delivered vaginal. Super happy. Mom's happy, baby's happy. Crying away in the room, both baby and mom. And so everything was fine. The point is, we did successful intrauterine resuscitation, but the nurses were sure because they know that I was. I practiced very conservatively. Like, well, Chapa's gonna. Let me just get that war ready. I mean, Chapa's gonna cut this woman. No, wait a minute, wait a minute. Number one, I'm kind of hurt by that. Two, let's fight for a vaginal delivery here. I mean, it only been about, you know, 15 minutes of lates. So it's still actionable. She had good variability, otherwise was low risk, except for her grandma to parody state, like, 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. So When I trained Dr. Cunningham, Dr. Levino, authors and pillars of MFM, authors of Williams Obstetrics, said, there is a C section, Choppa. There is one that you're going to regret. Anyone? Anyone? That's the C section you don't do. Because that's the one. In hindsight, you're like, oh, I should have gotten out. And. And so they kind of, you know, not trivialized the situation. But, like, you know, there's worse things in the section. Well, in this episode, we're gonna kind of highlight the reverse of that by summarizing two very eye opening and surprising facts about C section. Okay, now, both of these have to do with intrapartum C section. Intrapartum C section. Then we're going to highlight two articles here. These, of course, are recent. The first one is in the journal, the American Journal of Perinatology. This article just came out on 16th September, 2025, and the title is Impact of Labor in Perfect Primary Cesarean Delivery on Subsequent risk of Placenta Accreta. So let me just set the stage here. What this is saying is, hey, does it matter if it's a primary section not in labor or a primary section in labor? We know that section period raises risk of placenta previa, an abnormal placentation like accreta, in a subsequent pregnancy, but does it matter if that was in a laboring uterus or not? Okay, so with the assumption being that more C sections equals higher risk of both abnormal placentation and abnormal attachment, the morbidly adherent placenta, otherwise known as the placenta, create a spectrum. Let's see. Let's ask this question. Is what the author said, does it matter if that first C section was elective, not in labor? Let's say it's a herpes outbreak or breach, and she declined version, or for whatever reason didn't qualify for that, or the primary C section was done intrapartum. Are the risk of subsequent placenta accreta spectrum different? It's a good question. Now, this is not proving any kind of causation. This is a retrospective study. Okay. And we're going to get into this. But the, the findings there were very surprising. So why am I talking about this? Well, number one, again, this came out this month, September 2025, when we're recording this. And it makes us remember that let's not rush to a section just because, you know, X, Y or Z. Let's do it when it's necessary. But at the same time, we really do have to pay attention that there's questions that remain, like maybe, maybe the risk of a placenta accreta is different in the laboring uterus compared to non laboring. Is it or is it not? Well, I'm going to answer that. And then the second actually was brought to my attention by my wife, who is an EMDR therapist and does a lot of PTSD work. Right. So she works with post traumatic stress from either sexual assault Physical assault, family abuse, personal abuse in the past, whatever, and including childbirth, pain, childbirth, ptsd. She said, hey, have you heard, read this article in some, some journal called the American Journal of obgyn. I'm like, yeah, yeah, yeah, honey, I, I know what that, what that. And she said, well, it's interesting, something you may want to talk to the residents with, talk to the medical students about. And she's 100% correct. This was a very interesting issue that she brought to my attention. The title of this from the Gray Journal just in August. Guys, remember, we're doing this at the end of September 2025. This was last month. Just last month. The title of this personal perspective. So it's not a clinician, although there is fantastic data in this because the person who wrote this was a patient, but is also a journalist and is assistant professor of journalism or was when she had the C section in New York. So she knows how to gather the data. The title of this expert review. Now think about this. This is a non clinician who actually wrote this, but nonetheless, ajog, the Gray Journal put this under expert review. That says a lot. Now, the author is Rachel Summerstein. Okay, Rachel Summerstein. And the title is I Feel Pain, Not Pressure. A Personal and Methodological Reflection on Pain during Cesarean Delivery. This was in August of 2025, so I want to do this relatively quickly. I'm just going to get into the point here of. Don't, don't downplay worrisome signs. Intrapartum. If you see a Class 3 that doesn't go away, honey, you got to move on that. I mean, we'll worry about the placenta accreta the next time because we got to save this child, rescue this from metabolic acidemia. At the same time, you know, something that's more loosey goosey and potentially we have time to play with, maybe not run to rush to that C section because of its potential implication for placenta accreto as a subsequent pregnancy. Not just because it's a C section, but because a C section on a laboring uterus may carry different risk of PAs than in a non laboring. That's what we're gonna get into. And the second is just a reminder that, wow, when we tell patients, okay, you feel a little pressure as we press on the fundus or try to deliver that fetal head, yes, there's normal pressure, but if the patient is having pain, that's different. And always pay attention to verbal cues and have good communication with the patient. Of course, this is assuming that she's under a neuraxial anesthetic, typically if it's intrapartum, tends to be an epidural where most of these patients tend to have pain conditions. All right, so let me just set the issue here. Most of the data show that if a patient is going to experience pain intraoperatively at C section, it's with a topped off epidural. Now why that is, it's unclear, but compared to a spinal anesthetic, patients who have a topped off epidural tend to have more pain reported than those with a spinal cord. Now, we're not even getting into general. That's a whole other issue of general anesthesia and conscious awareness. That's a whole horrible other issue where patients are under general anesthesia and we've covered this in the past as well in past episodes and they're like, ah, you know, it's hurting but they can't say anything because they're under general and there's no vocalization going out. That's horrifying. That's a separate issue. But if it can happen under general anesthesia, we've got to be aware that this can happen under neuraxial. And the data support that is more likely to happen with topped off epidurals with intrapartum sections, as happened to this patient who was in her early 30s. She waited to have her first child. She had an intrapartum C section and it was incredibly traumatic for her because she kept telling him, I feel pain. And I said it's just pressure, you're fine. Though she was moving her legs and saying I have pain. So be aware of this. This is just a very quick awareness review and I'm going to give a startling data here on the percentages that have been published in the data of how rather infrequent it can be as like 1.4% of pain intrapartum for C section, to the other end as high as 36 based on how you define pain and how well you ask patients about it. Okay, so perhaps, perhaps I'm just throwing this out there as a good quality project for your resident research or your fellows research is take a look at those who had interpartum C section under neuraxial anesthesia, under an epidural specifically, and, and do a pain scale after, see how it went. What was your experience? Because what has been found is, is not addressing that in the immediate trauma event, in the immediate peripartum time, if you don't do that, then it can actually affect them and morph into this PTSD scenario, which is why my wife brought this up, because this patient, this author, Rachel Summerstein, who's a PhD, had EMDR, which is what my wife does. Right. So two things we're talking about. Does an intrapartum C section increase the risk of PAs over a non laboring C section? And what is this issue on pain during C section? Again, just two points of awareness as we talk about surprising facts about C section. Here we go. Tired of all the spin in women's health education. Yeah, so are we. This is Dr. Chapa's OB GYN no Spin podcast. Race the rudders. Raise the sails. Raise the sails. Captain, an unidentified ship is approaching. Over. Roger, wait. Is that an enterprise sales solution? Reach sales professionals, not professional sailors. With LinkedIn ads, you can target the right people by industry, job title, and more. Start converting your B2B audience today. Spend $250 on your first campaign and get a free $250 credit for the next one. Get started today@LinkedIn.com campaign. Terms and conditions apply. All right, podcast family. Let's first start with the publication from this month, which came out September 16, 2025, and then we'll backtrack to the one that came out last month in the Gray Journal. But the one from this month is the American Journal of Perinatology. Looking at retrospectively whether there was an increased rate of placenta accreta spectrum based on timing of C section. In other words, did it matter if the patient was intrapartum or not? This was interesting because this really hadn't been looked at that much. We just kind of assume and take it for granted. And it's of known fact, and the assumption is correct, that just having a C section period increases the rate of placenta accreta spectrum. And that is true. But the catch is here, when you had that C section, the timing of that primary C section actually does seem to matter in terms of raising the PAs. Placenta Creta spectrum risk. According to this retrospective review, primary cesarean delivery during labor increased the chance of having a placenta accretive spectrum disorder six fold. That's six fold in the subsequent pregnancy, which is something that we really didn't know before now. This is not the only one to show that scenario of the primary C section obviously increases the risk of placenta creta and how much damage, if you will, or salt, the uterus has at time of its initial surgery. But in this retrospect review, which did actually have multivariable logistic regression, so they took into account other factors, including Things like with this ivf, was it placenta previa? Did have postpartum hemorrhage? Did it have prior dnc? Even when you control for those things, guys, having a C section. So a labored compared to a non labored primary cesarean delivery, the risk ratio, the chance of having a placenta accretive spectrum was different. This is crazy. Now, this is not to scare you again into not doing a C section if a patient needs it. It's just another point of awareness that maybe we need to really pay attention to these things and not rush into it. So willy nilly. Not that any of us, I'm sure, none that any of us do that. But based on this, the adjusted risk ratio for a labored primary C section was 6.3. For subsequent PAs, the confidence interval, which is what matters here, guys, right? Did it cross one or not? And it didn't. Now it was close to 1, but it was still above 1.5. The confidence interval, listen to this. Was 1.7 up to 23.3. So it definitely was north of the 1.0 mark. Okay, so it is. There's something. Even though there was a pretty broad range there from a risk of 1.7 to 23, it's a broad confidence interval which has to do maybe a little bit with the accuracy, but nonetheless, this is surprising and it's something that we shouldn't ignore. It is retrospective. Again, there's things here that have to be figured out a little bit more, but it's something that we definitely need to keep in mind that a patient who has just one C section, and we know that the number of C sections is absolutely related to an increased risk of placenta creta spectrum, and it increases up to like number three and then dramatically after that. We get that. But even the indication for the primary C section seems to matter here for the risk of PAs. The title of this September 2025 publication was Impact of Labor in Primary Cesarean Delivery on Subsequent Risk of Placenta Accreta. I don't want to get into any, you know, a lot more details, but this was mainly out of UCLA as well as Tel Aviv, Israel. And well done. It was. It was a good publication. Just call into mind that everything has its risks and benefits. So don't ignore a C section because the relative risk is, you know, 6.3. But it is something that we need to take into account. And remember that C sections, all of them, but especially those intrapartum, potentially carry a risk not just in the immediate time of that delivery, but in the subsequent pregnancy. That's all I want to say about that. We'll leave it at that, because I thought that was interesting. And this next one we're going to do relatively quickly as well. This expert review from the Gray Journal from August of 2025. Just calling attention that, hey, some of these things the patient says, I'm feel I'm hurting, guys, it's not just pressure, stop. And according to this author's story, they didn't. They're like, oh, you're fine. And kind of kept going, led to ptsd. According to this journalist who authored this, this perspective, the rate of reported pain at C section is pretty broad because there's different ways to collect this. It depends on how you define pain. But as we mentioned in the Intro, anywhere from 1.4% up to 36%. 36. That's a third, guys. 36% of surgical births stated they had some kind of quote, unquote pain. And that's the catch. What does that mean? What do. What do you define as pain? And maybe set the patient up for expectation as they go into the or. Look, if you're hurting, you got to tell us. But if you have pressure, like a little bit, like you feel something kind of pushing on you, that's fine, you're going to feel that. But there is a difference. And we shouldn't minimize this difference between pressure and pain. We should embrace that and give the patient the information. And that's pretty much what this author is saying. Don't ignore it. And tell the patient both before the surgery and afterward, ask how she did. Because early intervention decreases the chance of PTSD and internalization. We've covered that before on another episode. So the point during the C section that the patient makes here is give patient awareness, respect, give patient awareness, 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. Whether that is giving something iv, doing local on the incision, which we've done before, to potentially saying, you know, I think we just need to go to sleep here and maybe convert this to general. But tell the patient so that she's aware, so that we can minimize the emotional and psychosocial impacts of this down the road from childbirth ptsd. The title of this expert review was I feel pain, Not Pressure. A Personal and Methodological Reflection on Pain during Cesarean Delivery. Very well written and again brought to me by my wife, the EMDR therapist. This patient did have emdr, which works phenomenally for childbirth related ptsd. So podcast families is relatively quick. I'm not going to give a bunch of data and a bunch of numbers, just 2 point points that I want us to remember. C sections. Even though it's the most common surgery in the world and relatively quote end quote routine until it isn't, there are things that we have to pay attention to potentially. According to one retrospective study, the risk of PAS is different with a laboring uterus than when not labored, even when other factors are controlled for. And the issue of pain is something we cannot ignore. Talk to the patient when she's under actual anesthesia, as we all should. Make sure she's okay as we're doing the procedure. And then once that child is out and they've had to time to bond, they've had their time for skin to skin. If that child has now moved on to the nursery, then let that patient rest to decrease her catecholamine flare. All right, podcast family, I thought that was relatively fast. Just two points to remember as we highlight these two articles from September and August of 2025. As always, we're thankful for you. We're glad you're part of our podcast community. Now that we've done all that, let's take it home. Podcast family. We're thankful for all the support that you've given us throughout the years. This has been the OBGYN no Spin podcast. We'll see you on the next episode. Sam.