Mailbag 31: “What does the Fox say” – With Dr. Nathan Fox

Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I am your host, Dr. Nathan Fox, an OBGYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

Hey, everyone. Welcome to our 31st “Mailbag” podcast. Our first question is from Daniela [SP]. “Hi, Dr. Fox. Love the podcast. Keep them coming.” Daniela, we plan to. “My question is in response to your podcast on twin vaginal deliveries. I understand that the second baby is often breech, and is manually extracted by the OBGYN or midwife. My question is, why does the second twin require manual extraction versus allowing the mother to push the baby out so-called ‘naturally’? I know that breech vaginal birth used to be more common. So, it is possible for a mother to vaginally deliver a breech baby. Why are twins different, or are they? Thank you.”

All right, Daniela. So, first of all, thank you for loving the podcast and listening. For our listeners who have not yet heard the twin delivery podcast, we dropped it first June 18th of 2020 with Melka. It was one of our early podcasts. And it was so good that we redropped it on November 8th of 2021. So, you can scroll back and look at those. But just as a review, we were talking about on the podcast delivery of the second twin, and you are correct. What typically happens is after the first twin delivers vaginally head first, for the second twin, there are basically two options.

One option is the baby’s going to come out head first and sort of mom pushes just like she did for the first twin. And the second option is that the baby comes out feet first, in which we go in, grab the feet, and basically pull the baby out, deliver the baby, what’s called a breech extraction. So, your question, Daniela, is why isn’t there a third option where basically the mother just pushes and the baby comes out breech, but through her pushing as opposed to us sort of doing the breech extraction? So, it’s a great question. And the reason is basically geometry.

So, after the first baby is delivered and the second baby is to be delivered, the only way to deliver a breech baby safely with the mother sort of just pushing and slowly coming through the birth canal, so to speak, is if the baby is positioned in the pelvis such that the butt is the leading part of the baby. So, if you think of a baby or think of a doll of a baby that’s sort of shaped in like a pike position, so the baby’s legs are sort of straight or maybe a little bent, but the knees are to the chest. Again, the feet might be pointing straight up, but it may be a little bit bent, but basically the butt is in there.

So, if that happens, like frequently happens with one baby who’s breech at term, conceptually, yes, the mother can push and then that breech or the butt sort of comes through the pelvis the same way the head would, and then the delivery, sort of the first thing you would see is the baby’s butt and so forth. So, that is a possibility when there’s a singleton, when there’s one baby inside who’s been there the whole pregnancy sort of snuggling into the pelvis butt first. We don’t do the breech delivery so much anymore, but what you’re talking about in the past, that’s how they were done. But for a second twin, that’s not the case.

After the first baby comes out, the second baby does not get a chance to sort of fall into the pelvis that way, because it takes a long time for it to get in there. So, either it comes down head first, in which case she can push and then the shape of the baby, since the head is like a nice sphere, can sort of get pushed into the pelvis and then through. But if the baby’s not head first and was presenting as the back or a leg or the shoulder or even the butt, it’s usually not in there. The baby’s sort of just lying in the pelvis. So, if she pushed, the baby’s not going to get into that right position to start fitting through the pelvis. And so, what has to happen for the second twin is basically we have to deliver the second twin feet first by grabbing the feet and pulling the baby out that way. It’s not just pulling. There’s maneuvers and this and that, but you know, for the sake of the podcast, well, for simplicity. So, great question, but that’s the reason it cannot be done.

Okay. Second question is from Alicia [SP]. “Hi, Dr. Fox. Love your podcast. Ever since learning I was pregnant, I’ve been binging all of your episodes. I’m currently 27 weeks pregnant, and had my appointment today. I’ve had a pretty easy pregnancy with no concerns. My anatomy scan showed no abnormalities, and baby boy’s heart rate has always been in a safe range. Today, my doctor heard an arrhythmia on the Doppler. She said she was able to get a baseline heart rate, but a few beats were skipped. She has sent me up with a MFM this week to confirm it’s nothing serious. She told me several times she is not concerned. My question is, how serious is this? Also, I’d just taken the drink for my glucose test. Could this have any effect on my baby’s heart? Thank you.”

All right. Good question, Alicia. Thank you for sending it in. By the time I’m reading this, all of this has already transpired. So, I hope all went well. And like your doctor, I presume everything is fine. To answer your second question, no, the glucose drink had nothing to do with this. Just put that out there. In terms of what we’re talking about, an arrhythmia is a fancy term for the baby’s heart rate rhythm to be different from usual. Right? The rhythm of the heart is usually a certain way. Right? Ba-bum, ba-bum, ba-bum, ba-bum, ba-bum, ba-bum.

And there’s two major components to that rhythm. The first is the speed. Right? So, is it ba-bum, ba-bum, ba-bum, which is sort of like how your and my heart rate probably is, versus a little bit faster, like a baby or fetus’ heart rate is, ba-bum, ba-bum, ba-bum, ba-bum, ba-bum? So, that’s the speed of the heart rate. We call that the heart rate, how many beats per minute. The second is the rhythm. And usually it’s very regular. Ba-bum, ba-bum, ba-bum, ba-bum, ba-bum. That’s very regular. There’s a lot of ways that could be irregular. And when it’s irregular, we call that an arrhythmia.

Technically, if the heart rate is too fast or too slow, we call that an arrhythmia, but it’s not really, it’s just too fast or too slow. An arrhythmia, typically when doctors think about it, it’s the heart is beating irregularly. So, for example, it could be ba-bum, bum, bum, bum, bum, bum, bum, just all over the place. That’s an arrhythmia.

Now, different arrhythmias mean different things, and it’s related to sort of the electrical conduction system of the heart. The way your heartbeat and anyone’s heartbeat is set is by very complex electrical wiring system within the heart that starts from the brain, goes through the heart, and it sort of…that’s why the heart beats at a very regular pace and a very regular rhythm. And there are ways that that can be disrupted, some of which are concerning and some of which are not concerning.

The ones that are not concerning that we see on babies or on fetuses are also more common. Meaning, if there’s any sort of arrhythmia on pregnancy, statistically, most likely it’s going to be one of the ones that is not concerning. So, that’s just…your doctor was just correct. Statistically, if there’s any abnormality in the rhythm of the heart, it’s usually one of the ones that’s not so concerning. And it’s the one that’s usually the easiest to hear, which is when there’s skipped beats, which basically means you hear like ba-bum, ba-bum, ba-bum, ba-bum. So, there’s just like a beat that doesn’t happen. So, that’s a skipped beat.

And sometimes you’ll see or hear the opposite, which is a beat that gets inserted, like ba-bum, ba-bum, ba-ba-bum, bum, ba-bum, ba-bum, ba-bum, like an extra one gets thrown in. Those two tend to be…and again, there’s ways we diagnose it and you sort of do an ultrasound, look at the heart, you do an echocardiogram, there’s all these things you can do, but basically they tend to be something called either premature atrial contractions or premature ventricular contractions, which is basically when the baby’s heart rate is…the rhythm is great, but every now and again, it’s sort of like, you know, takes a beat out of turn. And those tend to be very benign. They don’t hurt the baby during pregnancy. I mean, it’s not dangerous for the baby to be in that environment, and they typically go away after delivery. That’s the most common thing.

And so, if your doctor heard just by listening to the heart rate by the [inaudible 00:08:25] tone that there were some skip beats and you get the evaluation, frequently, what you’re going to find in this evaluation is either, no, the baby’s heart rate is totally perfect. Your doctor, you know, maybe just happened once, but it’s not going on anymore. You’re good to go. Or you might hear, yes, your baby has, every now and again, these premature atrial contractions or premature ventricular contractions. But otherwise, the baby’s fine, and healthy, and doing well, in which case, there’s really not much to do in pregnancy. It doesn’t have any implications for the baby. And again, they typically just go away after birth, and there’s not an issue.

And then, rarely, they say, no, there’s some arrhythmia that’s more concerning, and we have to do something about it because it could affect the baby or it could last after birth, and this is… Those are much more rare, much more complicated. But what you’re describing is typically one of the ones that is more common, typically not complicated, typically not worrisome to the baby, and typically just goes away afterwards. We make this diagnosis in ultrasound relatively frequently. We always take it seriously, do a full evaluation, make sure that’s all that’s going on. But typically, that’s the case.

Signs where the heart rate rhythm might be seriously concerning, that it’s a big issue, usually, the heart rate is, in addition to being irregular, super-duper fast, like not just a little bit fast, but super-duper fast, like in the 200s or something like that, or super-duper slow and irregular or something. And those are different conditions that we’re talking about here. So, again, like your doctor, just from what I hear in your question, I suspect everything was fine completely or was fine with one of those things, and probably went away either during pregnancy or after the baby was born.

Okay. Next question is from Rena [SP]. “Hi. Would you be able to include in one of your podcasts the topic of balanced translocations? For example, how common is it, how it affects fertility or treatment options or lack, if diagnosed, is it more common in men versus women? In other words, will my future sons or daughters be more affected by it and anything else you could share on the topic? Much appreciated.”

All right. So, Rena, basically, for…you probably obviously know a little bit about it. My guess from your question is maybe you have one yourself. But for our listeners, a balanced translocation is a situation where in your own DNA…right? So, all of us have 46 chromosomes. Typically, almost all of us have 46 chromosomes that are arranged in 23 pairs. You have pair number one, pair number two, pair number three, so to speak, all the way down to your 23rd pair, which is either your X or your Y chromosomes or you have two Xs or an XY. And that’s what we typically have.

And a translocation is basically where if you think of those chromosomes, those 46 chromosomes, think of a piece of DNA breaking off of one of those chromosomes and a piece of DNA breaking off of another one of those chromosomes, and they are flipped. Meaning, you have DNA from one chromosome that ends up on the other and the DNA from the other chromosome ends on that one. And that’s what a translocation is. And there’s two different kinds of translocations. There’s balanced and there’s unbalanced. Balanced means it was like an even split, an even trade that overall in each cell or in your body, there’s the normal amount of DNA. They’re just in the wrong locations. And an unbalanced or imbalanced is where that’s not the case of extra missing.

And what I like to…the analogy that I like to give to people is if, let’s say, you know, back in the day when I was growing up, we had these books on our shelves that were called encyclopedias. Right? An encyclopedia was pre-Google. Right? Pre-internet, pre-Google, where if you needed to learn anything or know anything, you had to actually open up a book. Yes, it was very, very dark ages. We were living in black and white. It was a tough time, but that’s how we used to roll. And you either had these at home or you went to the library.

And let’s say, there were, in the encyclopedia, 26 books. The first book was A, second book was B, C, D, all the way to Z. For example, if you wanted to do…look up anything on John Lennon, you would go to the L book and look under Lennon, John, and you would get, you know, a paragraph about him, pages about him, a chapter about him, whatever it might be. If you wanted to look up what is the capital of Uruguay, you would go to the U book, look under Uruguay and learn everything you want to learn about Uruguay. And that’s how we did it. That’s how we learned things back then. For you youngsters out there, yes, it was pretty awful.

Okay. So, that’s how it was. So, imagine, if you had, fortunately in your home, two sets of these. You had one set of encyclopedias in your study, and you had another set of encyclopedias in your bedroom. So, you had two sets of encyclopedias. For my Jewish patients out there, you can substitute this entire analogy for Talmud. Right? All your Talmud books, but I’m going with the generic encyclopedia version.

Okay. So, you have two sets of encyclopedias in your house, one in your study, one in your bedroom. Now, let’s say, for whatever reason, you took out the Uruguay book, and you took out from your study and you took out the Lennon, the L book from your bedroom. And when you put them back, you did it incorrectly. So, in your bedroom, you had 26 books, but you had no Ls and two Us. And in your study, you had 26 books, but you had no Us, but two Ls. If I came and did a survey of your home and said, all right, how many books, how many encyclopedias do you have? I would say, all right, you have two full sets. Two full sets, 26 books and 26 books. You have 52 books, you’ve got two full sets. But obviously, one of the sets is a little bit off because it has two Us, and one of the sets a little bit off and has two Ls, but overall you’re good. Your home has two full sets of encyclopedias. That’s a balanced translocation.

Now, an unbalanced translocation would be a situation where you, let’s say, lent somebody your Uruguay book and they sent you back a John Lennon book. So, now, in your home, you have an extra Lennon book and you’re missing a Uruguay book. So, if I went to your home and did a survey, I would say you have 52 books, but it’s not correct. You have too many Us and not enough Ls or the opposite based on what I said.

And in DNA, that matters mostly for reproduction and a little bit otherwise. So, if you have a balanced translocation, for most people who have balanced translocations, they’re not ill, they’re perfectly fine. They would never know about it unless someone tested them for it because they have the normal amount of DNA in their blood. And so, they’re fine. Every cell has the right amount of DNA. All right, some of it’s in the wrong location, but no big deal. Everything seems to be okay.

There are some exceptions. There are certain balanced translocations that people can have that increase their risk of certain conditions. Most notably, there’s a famous one that increases your risk of a certain type of cancer. And so, if you are diagnosed with a balanced translocation, typically, whoever diagnoses you will tell you if it’s one of the ones that increases your risk of cancer. Otherwise, it’s not. Most people who have them, they’re perfectly fine. They don’t know the difference. They’re great.

But the issue is you have a balanced translocation, and now, you’re going to have children. Right? So, when you have your two sets of your 23 pairs and you’re only going to send one set onto your next kid, if one of the sets has extra DNA and the other set has missing DNA, whichever one you pass on, your offspring’s going to get too much DNA or too little DNA.

So, going back to my analogy, let’s say you have the balanced translocation of encyclopedias in your home and you have two sets of 26 books. Overall, you have the right number, but your study set has two Us and your bedroom set has two Ls. Now, I give one of my sets to one of my children. They’re going to inherit a set that either has an extra U and a missing L, or they’re going to inherit a set that has an extra L and a missing U. And so, they will have an unbalanced amount.

And the reason that’s an issue is unbalanced translocations can be a very common cause of early… So, when people have multiple early miscarriages, part of the workup that we do is checking the parents if either of them has a balanced translocation, because they’re fine, they don’t know about it, but it might explain why every time they try to reproduce, they miscarry because those children are getting unbalanced translocations. They’re getting extra or missing DNA because they only get half from each parent. They don’t get both sets, they get one set.

So, my rule that comes up in that aspect in terms of the risk of miscarriage and we test for it, if someone has it, what do you do? Well, you can do IVF, and you can sort of test the embryos and make sure that you get the ones that don’t. And it’s a little bit complicated in terms of what is the likelihood because some sets are more likely to pass on versus others. And it’s a little bit complicated, but it is something that typically can be “treated” or addressed. You don’t change your own DNA, but you can change that. In terms of your question, how common it is, it’s pretty uncommon. I mean, even amongst people who have miscarriages, multiple miscarriages, it’s in the order of 2% or 3%. So, for people who are not miscarrying, it’s going to be even lower.

As far as I know, it doesn’t affect your fertility treatment options other than you’re going to need to do IVF and test the embryos. I mean, the other things people do for fertility, like getting hormones and this and helping you ovulate is not going to work because that’s not the problem. Right? The problem is you need to get into the DNA and pick the embryos that have normal. I don’t know if it’s more common in men versus women. And that’s really what I would share about it.

So, as an overall thing, it’s a very fascinating topic. It does happen. It’s not that common. For the majority, vast majority of people who have a balanced translocation, they’re perfectly fine. But some of them, when they try to reproduce, again, based on the translocation, based on luck, based on a lot of things, when they try to reproduce, they can have multiple miscarriages. There is a way to sort of circumvent that with IVF and testing the embryos, but not even everyone needs it. I mean, not everyone with a balanced translocation ends up with miscarriages, but is one of the possible causes. There are, as I said before, a few rare exceptions of balanced translocations where it can actually impact the person who has it, but that is the exception, not the rule. Okay. That was an in-detail question.

All right. Next question is from Bree [SP]. “Hi, Dr. Fox. Toaster here. My last pregnancy, I was diagnosed with IUGR, fetal growth restriction, at 38 weeks, and I delivered that same day because the baby was measuring small. I’m pregnant again, and my genetic testing revealed that my fetal fraction was 24%. I’m being referred to a MFM doctor. I did not do genetic testing for my other pregnancies. And I’m wondering if this fetal fraction number would have been high last pregnancy and, well, if I had done the testing, how concerning is this? My appointment is a few weeks away, and I’m trying not to freak out, but worried about my baby.”

All right, Bree, this appointment you had probably happened months ago. So, I’m sorry that I wasn’t able to answer it beforehand. So, as background, fetal fraction is a relevant data point when we do non-invasive prenatal testing, which is a genetic screen of the baby. And the way we do it is by getting blood of the mother. It’s sometimes called cell-free fetal DNA, sometimes called NIPT. Some of the commercial tests out there are Panorama, another one’s MaterniT 21.

There’s sort of a bunch of them, but conceptually, what they do is it’s a blood test of the mother when she’s pregnant. And in everybody’s blood, again, pregnant, non-pregnant, if you draw someone’s blood and you look inside, there’s going to be pieces of DNA that are floating around, we call cell-free fetal DNA. Meaning, it’s not within a cell, it’s just floating in the blood. And it’s caused by cells breaking down in the blood and the DNA getting spilled into the blood. Fine.

So, if you did it on me, for example, and you drew my blood and checked for the DNA that’s floating around, 100% of that DNA would be mine from my cells. Now, if someone’s pregnant, the majority of the DNA is from the mother, but there’s a small percentage of the DNA that’s actually from the baby. Technically, it’s from the placenta going into circulation, but we’ll just call it the baby because it’s typically the same as the baby. So, because that is true, the technology exists to sort of test the baby for genetic conditions using the DNA that’s in the mother’s blood. How they do it is very complex, very awesome, very cool. It’s almost science fiction, but it’s great. We could test for a lot of things with very high accuracy using that DNA that’s floating around the mother’s blood.

Now, in order to do that, there has to be a minimum amount of fetal DNA in the maternal blood, a certain percent. And usually, that number needs to be somewhere above 3% or 4% or somewhere in that range. And if it’s above that number, typically, they can run the test. And if it’s below that number, typically…not typically. Sometimes, they can’t run the test. It’s hard. Now, there is sometimes a concern in of itself if the fraction of DNA is very low, like if it’s 1% or 2%, that sometimes that itself, not only does it inhibit the ability to run the test, but it may indicate a problem with the placenta and a concern that maybe there’s a problem with the baby. Again, that’s a complicated topic itself, whether it alone warrants doing something like a CVS or an amniocentesis, or just repeat the test and see, because as you get more pregnant, the amount of fetal DNA in the blood tends to go up.

Okay. So, that’s when the fraction is too low. What you’re referring to, Bree, is when the fraction is too high. Now, what I would say is, in practice, typically, this does not come up that often. I rarely am seeing people where I’m concerned that the fetal fraction is too high. It certainly does not impact the ability to run the test. I think what you’re getting at is I looked up and there’s a study or two that suggests that if your fetal fraction is high and how it’s defined, let’s say somewhere above 20% or something like that, that there might be an increased risk of fetal growth restriction. No other adverse outcomes as far as I can tell, but it might be. It’s unclear exactly why that is, but that is, I think, what you’re referring to.

And so, what I would say as the answer to your question is, I don’t know if it would have been the case last pregnancy or not. There’s really no way to know because it’s not like the fetal fraction being high causes the fetal growth restriction. It’s that it may indicate something off with the placenta, which also could be fetal growth restriction. What I would tell you is, in our practice, we see many, many, many, many, many more people who have fetal growth restriction than people who have a high fetal fraction. Meaning, the vast majority of people who ultimately have fetal growth restriction did not have a high fetal fraction earlier in pregnancy. So, my guess is, if you could go back in time and check, your fetal fraction probably would have been normal, but that’s just because those are the odds. Right? They’re in my favor if that’s your guess.

Now, in this pregnancy, how concerned should you be now? Well, what I would say is, probably no more than you would be anyways. Meaning, anyone who has a history of a baby with fetal growth restriction, like you do, has a risk in the next pregnancy of the baby having fetal growth restriction again. And that risk is whatever it is based on the circumstances, but let’s say it’s double. Right? Whatever someone else’s risk might be, your risk is twice as high. Fine. So, let’s say it’s 10% in everyone else, it’s 20% in you. These are very ballpark.

From the studies, having a high fetal fraction might also double your risk. So, I would say it’s probably similar. So, I don’t know if the fetal fraction itself is particularly concerning in your case. Either way, no matter what your fetal fraction was, probably your doctors were going to recommend checking how the baby’s growing on ultrasound serially over the course of pregnancy. So, probably nothing’s going to change in terms of what to do. So, in those circumstances, I would say, probably it’s not much to worry about for you.

All right. Last question is from Megan [SP]. “How many caesarians?” Okay. “How many C-sections is reasonably safe? My first section was due to low fluid. The OB didn’t want to induce. My second pregnancy, I switched to midwives and did everything possible to have a successful VBAC. Read all the books, podcasts, chiropractic care, etc. I wound up with a failed VBAC induction after no progression, passed 5 centimeters after 27 hours of labor. I’ve always wanted four kids, but the State of New Jersey is not VBA2C, that’s an acronym for having a VBAC after two C-sections, friendly. Is it more risky to try VBAC or have four C-sections?” Right? You have four kids. “In your most recent episode with Dr. Melka, you mentioned placenta accreta on the fourth C-section and the dangers of that. Would you ever do podcasts on multiple C-sections?”

So, we’ve done a bunch of podcasts on C-sections and accreta and talking about this. I don’t know if I’ve done it specifically on your question, but I will try to answer it. The short answer to your question is, in my opinion, if you have a good surgeon and he or she knows what they’re doing, there is no specific number of C-sections that is a cutoff for safe versus unsafe. Meaning, every time you have a C-section, whether it’s your first, your second, your third, your fourth, your fifth, so to speak, there is a risk of complications.

The complications we’re talking about are things like, all right, infection, bleeding and requiring a blood transfusion, potentially damage to some of the surrounding organs, hysterectomy, having to be admitted to an intensive care unit, and obviously, God forbid, dying. Now, that one is exceedingly rare in all cases.

But in terms of the other risks, they do go up with each C-section you have, but they don’t tend to be numbers that are markedly different. Meaning, let’s say the risk of a blood transfusion or a placenta accreta or something like that. Let’s say, for your first C-section, blood transfusions… I’m making this up. Let’s say it’s 1% and placenta accreta is less than 1%. And if you’re having your fifth C-section, the chance of blood transfusion is 2% to 3%, and the risk of an accreta is 1% to 2%. So, they’re higher, but they’re still not high.

The exception is if you happen to also have what’s called a placenta previa. If you have a placenta previa and you have multiple prior C-sections, then you have a much higher risk of bleeding, a much higher risk of placenta accreta, a much higher risk of needing hysterectomy and all those things. But that’s true if you’re on your third C-section or your sixth C-section, your fourth C-section, your fifth C-section, whatever C-section you have above maybe two. Right? If you have a placenta previa, you’re at high risk for all these things.

So, it’s not that each individual C-section you have increases your risk of these things markedly. It’s that every time you have a C-section above three, there’s a chance you won’t have a placenta previa, about 95%, in which case it might be a tough C-section, it might be hard to do and, okay, you may have a harder recovery, this or that. And there’s about a 5% chance of having a placenta previa, in which case, all those other things are much, much higher.

And so, when people…in my experience, when doctors tell patients, you should not have any more babies because you’ve had too many C-sections, that’s usually for one of two reasons. Reason number one, which I believe is the more common reason, is the doctors saying, you know what, enough is enough. You have enough kids, three, four, whatever it is, that’s enough. You don’t need any more. Why take any risk? Which is, I think, a little bit on the judgmental side of things. They’re putting in their own judgment about how many kids is enough.

The second reason why a doctor might say that is, listen, you specifically have a complicated or had a very complicated C-section. You have complicated anatomy, whatever, a difficult time. I think, if you had another C-section, it would be far riskier than typical. Right? So, I’m seeing someone who had four…let’s say, for you, three prior C-sections. And they’re saying, I want to have a fourth. If the third C-section was relatively uncomplicated, you know, went okay, nothing crazy happened, I would say to them, all right, listen, with the four C-sectioners, there’s risks. Obviously, you’re having a C-section, you’re having surgery. If you have a placenta previa, which is about 5% chance, you have a lot of risks and you need to have very high-risk care and this or that. But if you don’t have a placenta previa in the 95%, most likely, it’s gonna go pretty similar to the last one you had. And I wouldn’t make any judgments on how many kids is right for that person or that family. That’s not my place. Who am I to say? They know how many kids they have. I don’t have to remind them.

And so, I would say the same thing where someone’s having their fourth, someone having their fifth, someone having their sixth, someone having their seventh. The conversation is the same. If everything pretty much was okay the last time, they next time, 95% of the time when you don’t have a previa, it’ll probably go okay. Again, there’s exceptions, this and that. And the other times, it’s high risk, but it’s not really based on the number. And I try not to give judgments about that.

Now, there are people who have very complicated C-sections, a complicated anatomy, and things happened [inaudible 00:29:29]. Tell them, I think you specifically might not be a good candidate to have a fifth C-section or sixth or seventh, but there’s a reason. There’s a specific reason that’s beyond just the number. And I think that’s a very important distinction. If you’re meeting with your doctors and asking them and they say, I think four C-sections is the maximum, I would say to them, is that because it’s always the maximum, like, you just believe that, that there’s…no one should have more than four kids if they’re C-sections, or is there something unique to me, my health, my prior C-section, my anatomy, whatever it might be, that’s putting me at a specifically higher risk compared to someone else? And then that’s a different conversation. And so, that’s how we approach it in our practice.

Now, I happen to think that the people I work with are terrific surgeons, and I think that that does help if you operate on someone and you think it went well. You’re more confident with the next one than if they came to you from somewhere else, where you don’t really know how great of a surgeon they are. And if I know they’re a great surgeon, fine. But it’s one of these things where that’s why we sort of…we like to see the patients after we do a C-section, talk to them about the next one, because we just did the last one. I think that’s sort of the better way to go. But when you ask that question, it really is important to clarify if someone’s giving you a no or it’s too high-risk, say why. Is it, again, just the number, or is it me specifically? And those are…if it’s the first, then you may want to get a second opinion. If it’s the second, then I would try to get very, very detailed why. And there may be very good reason why, but there should be one.

All right. Thanks, everyone. Great questions. We’ll see you all next week.

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