“What happens during a C-section?” – with Dr. Katherine Ida Halper

Dr. 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’m your host, Dr. Nathan Fox, an OB-GYN 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.

All right, Dr. Halper, K.I., welcome to the podcast. This is your first time on the Healthful Woman podcast, so welcome aboard.

Dr. Halper:Thank you. Happy to be here.

Dr. Fox: It’s good to have you. So you are a recent join to our practice. We are happy to have you aboard and it’s good for our listeners to meet you, those who are in the practice and those who are listening throughout the world to know who you are, to meet you and get a little bit of your insight. We’re going to talk today about cesarean deliveries and sort of what happens during the C-section. But first, just so people get a sense of who you are, give us a little background. Like, who are you? Where are you from? Where did you go to school? Things of that sort. Open-ended question. Any way you want to answer is cool.

Dr. Halper: Okay, sure. So I grew up in New York City, so I’m happy to be here for the long haul, hopefully. I went to medical school in Israel at Ben-Gurion University. I then came back to New York, actually to Brooklyn for several years where I was at Brooklyn Methodist Hospital where I did my residency. I graduated this year and then I just started here with MFMA in September. So it’s been great so far.

Dr. Fox: Terrific. The full circle back to the city.

Dr. Halper: And hopefully to stay.

Dr. Fox: To stay. Good job. We’ve been happy to have you for the past several months and as have our patients. And what’s it like shifting from residency to being the big boss in private practice? How’s that transition working for you?

Dr. Halper: It definitely is an adjustment. In residency, you spend a lot of your time, I would say majority of your time in the hospital, mainly on the labor floor or in the operating room or taking care of patients on the floor while they’re inpatient. Whereas, you know, in private practice now, majority of the time, I would say, is seeing patients in the office and then a couple days a week or so on labor and delivery or in the hospital doing other things. So it’s definitely a shift as far as how I spend the time. So it’s, you know, it’s exciting. It’s different, but it’s the same, seeing the same things in sort of a different setting.

Dr. Fox: Yeah, and I think that that’s, a lot of people don’t really understand what happens during residency. You are based in a hospital. Obviously, there’s outpatient experiences in the hospital. You know, there are like offices and clinics and whatnot. But as a resident, so much of what you’re doing is learning how to do things, right? And so you have to learn how to operate, learn how to deliver babies. And so so much has to be done in the operating room. And it’s part of the reason that I wanted to do this podcast to talk about C-sections because, you know, C-section is a major operation, you know, from our end, right, where it’s surgery. It’s the real deal. And I don’t know if people appreciate how many of these we do in training in order to get good at them. So if you were to estimate, like, how many C-sections do you do during your residency, would you guess?

Dr. Halper: I would say somewhere in the 300s at least.

Dr. Fox: Yeah, many, many hundreds. Right. It’s not like…

Dr. Halper: Maybe more.

Dr. Fox: It’s a lot.

Dr. Halper: Yeah, it’s definitely a good amount. And you start from the beginning of your intern year pretty much. I think I started in my third month of residency.

Dr. Fox: Right. And it sort of gets to the point during your training that by the time you finish, like, when you dictate a C-section, when you like, the steps are like one, two, three, you know them like the back of your hand, you know them like you could be woken up at three in the morning and someone say, like, “What clamp do you use for this?” “Nope, that’s a Kocher. I know.” And it’s just like, it’s really become second nature, which is important because when you’re operating so much of it is muscle memory and knowing where to stand and where to turn your hands and where to do this and what to look for and what to think for. And you have to do a lot of them to get good at them. And so I think that sometimes when we as doctors talk to patients about C-sections, we sometimes forget that they don’t know anything about it. They have no idea what’s going to happen, right? They know they’re going to go in an operating room, we’re going to do something and a baby’s coming out of their belly and then they leave. Right. And so I was hoping for this podcast, we could sort of, not in a guts and gore kind of way, but just sort of go through what someone can expect for what’s going to happen if they’re going to have a C-section, both sort of from their perspective as the patients, like their experience, what they’re going to see, what they’re going to feel, what’s going to happen. And from our perspective, what we’re doing just so they get some clarity. And there’s probably some stuff online on this, but this might be hopefully a little bit less terrifying.

Dr. Halper: Totally. And I think what’s really interesting about C-sections compared to pretty much every other surgery is you’re actually awake for it. So that is something that kind of sets this type of surgery apart from most other surgeries that people will have in their lifetime.

Dr. Fox: Yeah, and that’s something that I talk to patients about, but I always like when I’m operating with residents, I remind the residents, I’m like, “Hey, this person’s awake. Right? So when we walk in there and we banter with each other and we’re talking and, which is cool. Like, you know, we talk about this, we talk about whatever, we talk about the operation itself. We talk about just nonsense. They’re listening. Right. So be very careful. Like, like we don’t want to say things like, oops, you know, never seen that before. Right. These are things we don’t want to say.” Hopefully, it won’t happen. But obviously, you don’t want to say it because you don’t want to freak anyone out. You just want to, you know, keep everyone aware that everyone in the room is awake. Hopefully. That’s the plan.

Dr. Halper: Totally. What’s also nice about it, I feel like, is you can actually continue to communicate with the patient the whole time. So you know, you can check in, they can ask questions, you can, you know, at least have some communication, which again is not something that you can do in almost any other surgery.

Dr. Fox: Yeah. I mean, you see how things are going great. Everyone looks good. We’ll be, you know, baby will be out in five minutes. All those things. So people can [inaudible 00:06:26]. And as the patient, you’re allowed to talk. You’re allowed to ask questions. I mean, obviously if they’re busy and concentrating on something, they may, it depends on the circumstance, you know, what’s going on. But you could say, “Hey, like what’s going on? Is everything okay? You know, I feel this, I feel that. Is that normal?” That’s totally okay. And either the surgeon will answer or maybe the anesthesiologist or maybe one of the nurses, again, depending on the question and the circumstances.

So let’s talk about before the surgery, right? So there’s sort of, I think we could divide up into like preoperative, what we call sort of, which is before the surgery, then in the operating room before we start, while we’re doing it. And then after it’s finished. So preoperative, right? Someone’s about to have a C-section. This obviously might differ based on whether it’s a planned C-section, right? Someone says, “I’m going to the hospital on Tuesday to have a C-section,” versus someone who’s in labor and we switch plans. We say for reasons A, B or C, we have to switch and do a C-section. Okay. What are the things that we do and patients can expect to happen before surgery, preoperatively?

Dr. Halper: So before the surgery, one of the things we’ll do is we’ll scan the baby. We want to know what position the baby’s in so that we know what to expect when we go in. We will also do some basic blood work just to make sure we kind of know our starting blood count. We have, we know the blood type. We have blood available if needed so that we’re just, you know, prepped and ready to go. With any kind of surgery, there’s always a risk of bleeding. So we like to just be prepared. Other things that we think about, we want to just make sure that we know the whole complete medical history, surgical history of the patient. Anyone who’s had multiple prior surgeries, we can expect that there could be some scar tissue, that the surgery could just take us a little bit more time. We like to just sort of at least set expectations both for us to be on the same page with the patient and with everyone else in the room. We also obviously give everyone a chance to ask questions, to come up with any last things that they want to go over before the surgery. We usually sign the consent form and just go through everything one last time.

Dr. Fox: Yeah, I mean, ideally before surgery, it’s intended to be a time that we’re trying to reduce anxiety, you know, to make people feel more relaxed. Going into surgery is obviously anxiety provoking for everybody. That’s totally normal. So having that, again, and usually if it’s planned, we’ve already spoken about it even in the office and for days or weeks or whatever. But it’s really nice that people come with questions or people forget something and they won’t have an opportunity. It gives them a nice chance. Also, usually they get to meet the nurse beforehand, the anesthesiologist. And again, unless someone’s already in labor, they’re typically walking into an operating room, right? We don’t have to wheel them in. They don’t get put to sleep or anything like that. It’s really meant to be something that’s as less scary as possible under the circumstances. And so having conversations on the front end definitely allows [inaudible 00:09:25], and then on our end, there’s definitely like you said, things we want to check, you know, to make sure that everything’s okay and set expectations. How much time does it take? Do we need more surgeons there? Do you need more equipment there? Whatever. In rare circumstances, there’s things that we might need. Usually not, but that’s a possibility. So that’s all preoperative. Everything is set up. What happens when someone walks into the operating room for their C-section or they’re rolled in if they’re in labor?

Dr. Halper: Right. So it kind of depends. If they are walking in, the first thing that we’re going to do is get them set up and comfortable on the operating room table, introduce them to anesthesia once again and get them ready to get into position for their epidural placement. So that is on the side of those who are coming in for their planned C-section. If they’re wheeling in, they already have an epidural in place. So usually at that point, we kind of get you situated on the table and then start our prep procedure a little bit more quickly.

Dr. Fox: Right. And usually for this part of the preparation, we usually bring people in alone without their partner. So why is that? Like why do we have someone wait outside rather than having them come in together?

Dr. Halper: Well, so we have a lot of things that we need to do. A lot of OR personnel who are also getting everything set up. We have our table that we’re getting set up with all the sterile instruments and making sure all of our prep is set up. We are listening to the baby. That’s one of the things that we do. We get you connected to some monitors. We’re placing if you don’t have an epidural already, a Foley catheter after the epidural comes in. So we have a bunch of kind of tasks where people are moving sort of in a very sort of rhythmic way that we’re used to. But having an additional person in the operating room, I think, would just kind of potentially upset that rhythm a little bit. And I think also keeping the partner a little bit separate from some of the more kind of clinical and like measurements and prep work is kind of better. Instead, they come in when the patient’s already set up on the table. They go behind the curtain with the patient and the anesthesia team. And we keep them sort of separate from the actual surgical aspect.

Dr. Fox: Yeah, I think that’s a good point. I think it’s again, it’s unusual in general when people are having surgery that anyone goes in the operating room with them, right? People go into operating rooms alone and they come out alone. Right? That’s very typical. C-sections are obviously unique because number one, the patient’s awake and number two, there’s a baby being born here. And so that’s a very special event in addition to surgery. And so we’re trying to balance sort of keeping it a happy and light and sort of joyous moment on the one hand, but on the other hand, not forgetting that this is surgery. This is serious. Like, we have sterile technique. Like, there’s things we have to do to keep it safe. And I think that, you know, I agree that having someone in the room while we’re doing all these technical things could be logistically complicated. Sometimes they bump into the wrong thing and then something’s not sterile or, you know, someone is doing something and it feels like they’ve been slighted and they get offended. You know, like all these things happen. But also it’s a little disconcerting. It’s like scary to see someone getting set up for surgery. You know, they get…we have to disrobe them and we have to like, move them. And then with the spinal, they can’t really move themselves. It’s like move their body. And it’s hard to watch a loved one get prepped for surgery. And so we sort of want it to be like very, so like we get everything set up, you know, get all the drapes on. It’s nice and blue and everything looks perfect and clean and neat. And then the partner walks in and like sits down and everyone’s blood pressure is nice. No one’s pulse is going up because of this. And I mean, the two people at the other end of the curtain, the patient and her partner, like for us, it’s not, you know, doesn’t…no sweat off our back if someone’s watching us. It’s not an issue, but it tends to be a little bit calmer that way.

It’s very similar to sort of like a lot of times when someone’s having their epidural placed, they’ll either ask the partner to step out of the labor room or sit down on a chair and not see because we also don’t want someone getting lightheaded or, you know, we don’t want any partners passing out in the operating room. That’s not a pleasant day when that happens. So but that’s something to expect that usually you go into the operating room alone. But assuming you’re awake for the operation, your partner will join you after the prep is done before we start. And for the person who’s waiting outside, it can sometimes feel like a long time. It’s not like two minutes.

Dr. Halper: Yeah, I usually like to tell people expect to sit here for, you know, 15, 20 minutes. Great if it’s faster. Amazing. But that we just have to do our usual setup, our usual prep. It’s all just the stuff that we do all the time and that, you know, they’re not going to miss any of the action. But we will call them in when it is their time.

Dr. Fox: Right. And another thing that sometimes people are surprised to hear is we have these things in the operating room we call timeouts. Someone will yell like, “Timeout.” Can you explain what that is so people aren’t wondering why there’s a sporting event going on in the middle of their surgery?

Dr. Halper: Sure. The timeout is the opportunity for all of us, all of the operating room personnel, the doctors, the nurses, the pediatricians, who, by the way, are in every single C-section. Just wanted to mention that they’re there no matter what.

Dr. Fox: In our hospital, not in every hospital.

Dr. Halper: Oh, sorry. And the anesthesia team, scrub techs, everyone is on the same page about, you know, we’re confirming the patient who we’re performing surgery on. We are confirming, you know, the medical situation, the indication for the C-section. We are just making sure that everyone is on the exact same page before we start to make sure that this can be done as safely and smoothly as possible.

Dr. Fox: I mean, timeouts sort of classically started for things like patient’s asleep, we’re about to replace a knee. Does everyone agree that we’re doing the left knee, not the right knee, so you don’t accidentally replace the wrong knee? And that’s like the classic like, oh, my God, like, do not get this wrong. And so you would say like, well, we’re not going to do a C-section on the wrong, you know, part of the body. Like, and so but there’s so maybe that part isn’t as relevant for a C-section, but were antibiotics given? Do they need to be given? You know, is there anything special we need to do with the placenta? Are we like, sort of everyone’s just sort of on the same page? And also, what’s nice is we all introduce ourselves by name. We go around the room and everyone says who they are. It’s like roll-call. And because you don’t always know. There could be 12 people in the room and the patient doesn’t know and maybe not all the doctors and nurses know who everyone is. Like, is she from anesthesia or is she from pediatrics? And so you don’t…it’s nice for everyone to sort of do that because there’s a lot of people who work in a hospital and you don’t always know. So that’s something to expect. And usually there’s at least one and sometimes two of those in the operating room before we start. We obviously, we do something called an instrument count where you’ll hear someone saying like, you know, “Two of this, four of this, six of this, eight of this.” And that’s just to make sure that the same number of instruments coming in are the ones coming out. So we didn’t leave an instrument behind, so to speak. That’s an important part of it. And we always check that the anesthesia is working at this point several times. But that’s another concern people have before surgery. How do I know this isn’t going to hurt?

Dr. Halper: Yeah, so that is definitely something that we make sure of before we start. But it’s also important to remember in a C-section, yes, we test you to make sure you don’t feel anything sharp. But the thing that I always tell people is, “Yes, you’re very numb, but you’re still going to feel things going on. You’re still going to feel touching and sometimes pulling and pressure. And those sensations can’t, we don’t take that away.” So just setting that expectation in terms of no, you shouldn’t feel sharp. And we make sure of that before we start. But you will feel something.

Dr. Fox: Right. And the other thing that happens that is sometimes people forget is between the patient being sort of ready and in position and us doing all of the prep work, we have to leave the operating room and then come back in because we have to wash our hands. The surgical scrub, as it’s called. So it’s to be expected that you’ll have all these people in the room and then your doctors are going to leave you for a couple of minutes and then come back usually with wet hands, fingers pointed to the ceiling. So, you know, you want us to be sterile when we start this operation. So, okay, so we’re all prepped. We put all the drapes on. The partner comes in and then we’re about to start. And so what happens at that point?

Dr. Halper: When we take the first decision, you might hear someone say, “Skin.” That just alerts everyone in the room that we are actually starting the surgery itself, just so that everyone can be aware when the procedure actually began. Basically, at that point, we make our skin incision and then we kind of continue through the various layers of the abdominal wall, which is we go through fat, we go through fascia, we go through muscle, peritoneum, which is the sort of like lining in front of the internal organs. And then we get to uterus.

Dr. Fox: So from the patient’s end, how long does that take from when we start to when we’re about to deliver the baby?

Dr. Halper: It’s a great question. This can really depend on how many C-sections you’ve had in the past or how many abdominal surgeries. In someone who it’s first surgery ever, anatomy should be pretty much exactly as you were born with. So getting down to baby can be, you know, anywhere from three to ten minutes in those situations, I’d say, or if it’s a very urgent situation, sometimes even under a minute. But in those people who have had multiple prior surgeries or many more C-sections, that time can be quite a bit longer, sometimes more in the range of 15, 20 minutes. And that is expected because there can be scar tissue that we have to go layer by layer and very carefully go through in order to safely get to the uterus.

Dr. Fox: Right. And so from the patient’s end, so there’s the time aspect. And what should she be? What should her sensations be at that time? So she’s not going to feel sharp pain. And we check for that multiple times. So what might she feel while this is happening?

Dr. Halper: Yeah. So in the beginning, you might just feel some like pushing and touching. And then when we get closer down more towards the muscle, you might feel some like tugging and pulling and like kind of stretching.

Dr. Fox: Right. And then a lot of people during this time report that they have like lightheadedness or dizziness. Is that related to the surgery or is that more the anesthesia?

Dr. Halper: It’s usually related to the anesthesia.

Dr. Fox: So what’s going on and what should people expect with that?

Dr. Halper: So the epidural can or the epidural anesthesia can lower the blood pressure. It can make people feel dizzy. You also, depending on the type of medication that they’re dosing you with, it can be pretty like medication, which can just the side effects can make you feel nauseous. Sometimes people have nausea or vomit on the table, which can be an unpleasant sensation. But it can be part of the experience, unfortunately.

Dr. Fox: Is that something that they can treat typically?

Dr. Halper: Yes, they can give anti-nausea medications, which can be helpful. But sometimes people will still feel uncomfortable throughout the process.

Dr. Fox: Yeah, I would say it’s important. And usually the anesthesiologist will say to you, like, “Let me know if you feel nauseous or dizzy.” And they can either give you nausea medicine or sometimes raise your blood pressure to fix it. But that’s something that if they haven’t asked you that, but you’re feeling that you can speak up. Again, you can say, “Hey, I’m a little dizzy here. I’m a little nauseous. Is there something you can do?” And usually, it’s something they can address pretty quickly. And that’s not usually from the surgery part. There are other times in surgery that might be the case, but not for this part. So, okay, so we’re at the uterus, right? And so, what should people expect at that point? And what do we do at that point? So now that we’re looking at the uterus.

Dr. Halper: Okay, so at that point, we are ready to make our incision, which is going to be our big-time action of the surgery, the exciting moment. So that usually takes about maybe 20 seconds to kind of get through the layer of the uterine wall to the baby. Once we get through, basically, we expand the space to get our hand in to either deliver the baby’s feet or butt or head, depending on the position of the baby. And at that point, basically, once we have the, what we call the presenting part, which is the part that’s at the uterine incision, you’re going to feel tons of pressure on your belly, which is called a sort of a fundal pressure. And that is going to help to get the baby out. But a lot of people describe it as a very intense pressure on their belly.

Dr. Fox: And that’s because someone’s generally pushing on their belly.

Dr. Halper: Yes.

Dr. Fox: Yeah. It’s very accurately described as pressure on the belly. And so, and then a lot of people ask if they can see the birth. So is that an option?

Dr. Halper: So, that is an option. We have a drape set up so that basically, if you want to see the baby actually coming out, we can drop the blue curtain. And there’s a clear drape, which you can see through for the actual delivery portion.

Dr. Fox: Right. And it’s pretty cool. It could be freaky for some people as well. And so, that’s a choice to make for both you as the patient and your partner. And then, so we deliver the baby. And then what do we do?

Dr. Halper: So at that point, we ideally, if everything is great, we can do a delayed cord clamping for a minute. And at that point, we’ll hand the baby off to the pediatricians for evaluation just to make sure that baby has good vital signs, is crying, is vigorous, is doing all the things that we want the baby to do on first landing into the world.

Dr. Fox: Right. At this point, it’s always someone’s always going to ask, “How much does the baby weigh,” before we weigh the baby. So that’s a very typical thing. “How much the baby weigh?” “Haven’t weighed the baby yet.” And then as Mike Silverstein always says, the top question is, “Why is the baby crying so much?” And we always say, “It’s a good thing.” And the second most common question is, “Why isn’t the baby crying so much?” And we say, “It’s fine.” But something to remember is that at this point, so after we’ve delivered the baby, we’re not taking care of the baby. Right. We’re focused on you because we’ve just opened your uterus and taken out your placenta. And there’s bleeding and there’s sewing. There’s a lot of things. It gets very busy for us at that point. And so we may not be as attentive to your questions as you might like during those next five minutes or so, because there’s a lot of things we have to do to keep you from bleeding. So what are the things that we have to do, like after the baby’s out, that we really start working fast?

Dr. Halper: Right. I think that’s actually a really great point and something that a lot of people forget that the pediatricians are now in charge of the baby and we are in charge of you and keeping you safe. So the first thing we have to do is to deliver the placenta. So that usually happens within a minute or two of the baby coming out. And at that point, what we’ll do is we want to get the bleeding under control. So the first thing we have to do is, you know, close the uterus. But many of us in order to close the uterus and get a really good look at everything, we’ll do what’s called, it’s called exteriorizing. I’m saying that with like quotes, but basically where we lift the uterus sort of and out of the belly, it’s still connected to you. Don’t worry. But we lift it out so we can get really good visualization. We clean it out to make sure there’s no pieces of placenta left inside to the best of our abilities. And then we will start closing it.

Dr. Fox: Yeah, that’s something that most patients and partners don’t want to see. It’s like when you have a med student who’s there for their first C-section and you exteriorize the uterus, and there’s literally like this internal organ, uterus, tubes, ovaries, just sitting on your belly and like literally sitting right on top of it. And we’re operating on it outside the abdomen. They’re like, oh, my God. And but no, it’s something that we don’t do it in all cases. It depends on the circumstances. But it is a pretty, anatomically, it’s a pretty cool thing. Medically, it’s a pretty cool thing. But it’s a little freaky if you’re not like, trained. But that’s something we sometimes do. So it’s usually at that point after the baby’s born that we’ll typically put that drape back up, ask the partner to sit down, like, “Look at the baby, focus on the baby. Don’t look over here. We’re going to do our thing,” and do that. And we’re working quickly because, again, the faster we close the uterus, the quicker the uterus contracts, the less bleeding there is and whatnot. So those are things [inaudible 00:26:07]. And we don’t if we don’t exteriorize the uterus, it’s still the same things. But it’s just we’re operating, everything’s inside the abdomen versus outside. So, okay, so we close the uterus. And what do we do next?

Dr. Halper: Okay, so we’ve closed the uterus. We usually put it back inside after we’ve looked around.

Dr. Fox: I would say we always put it back inside. But yeah, but that’s good. We’re going to keep that. All right. We usually put it back inside. I would say always, but that’s fine. It’s done differently. Maybe in Brooklyn, they usually put it back inside and then leave it out the rest of the time. There we go. See, I got Dr. Halper with the funny, got her to laugh. Good job. All right.

Dr. Halper: Yes, we put the uterus back inside and then we work on closing the remainder of the layers. And, you know, there is different evidence out there. People do this different ways, but I know that many of us in our practice really like to close every single layer that we’ve opened.

Dr. Fox: Yeah. We’re fastidious.

Dr. Halper: And we close everything that we can do safely. Obviously, there are some situations, like I mentioned before, when there’s a lot of scar tissue when someone had many surgeries in the past where it’s not doable to close each layer, layer by layer. But we do as much as we can.

Dr. Fox: Right. And again, the disagreement about this is sort of on the one hand, the argument is, you know, everything you open, you should close, put it back the way you found it, you know, those types of things. And there’s a lot of logic to that. On the other side, the argument is you might not need to close all those layers because they’ll heal on their own. And maybe you’re just taking more time and prolonging the operation, which may have some risk. And there’s some validity to that as well. And there have been studies looking at each individual layer, which ones matter, which ones don’t. And the short answer is nobody knows 100% any of these things. Everyone, you have to close the uterus. You have to close the fascia. You have to close the skin. All the other ones are sort of, I don’t want to say optional, but people disagree about them. We tend to close all of them, like you said, if we can. That takes a lot more time than opening them. You know, putting things back together takes a lot more time than opening them up as it turns out. So how long should patients expect? Let’s say you said it’s three to ten minutes from opening the skin to getting to the uterus. How about the reverse? From the uterus getting back to closing the skin, how much time would it typically take on a first C-section?

Dr. Halper: I would say probably in the range of probably around 30 to 45 minutes.

Dr. Fox: Yeah, it’s a lot longer. It’s a lot longer on the back end than the front end.

Dr. Halper: For a first C-section. Could be longer in a repeat C-section. Kind of depends on the situation. But I usually tell people just in general in the operating room with a C-section to expect at least surgery to take at least 45 minutes to an hour, but know that that time can always be longer. We like to take our time. We don’t want to rush. So, you know, whatever it takes to do it safely is what we’re going to do. And also, OR time door to door can be more like two hours between getting you into the operating room, getting you set up, getting the surgery done and then getting everything cleaned up, too. So, you know, the operative time itself might not actually be as long as the full time of the door to door full procedure.

Dr. Fox: Yeah, it’s a really good point. Like, I tell patients the same thing. I said, “For you getting operated on, from we say we’re starting to we say we’re finished, it could be 30 minutes, 45 minutes, 60 minutes, you know, whatever, based on the surgery. But for your loved ones who are in the waiting room and the hallway at home, when you text them, you know, ‘I’m going in,’ and then you text them, ‘I’m now in the recovery room,’ it could be two to three hours because going into the operating room, all the prep time, all the things that we do before surgery and after surgery, which aren’t surgery, but for someone who’s at home, they have no idea what we’re doing.” So to warn them that it might be longer than that, which is normal from sort of their end of the experience. When we’re closing, there’s sometimes some nausea that happens. It’s not related to blood pressure. And I think that’s a unique thing that it could be related to the surgery, because some of the layers we operate on when we close them are a little more sensitive. So sometimes that’s a different kind of nausea. So that’s something that some people will experience during the surgery. And that’s just important to expect. And then when we close, right, no one’s going to sort of see what we’re doing, obviously. They just see the incision afterwards. So how do we close the skin typically, like the final part?

Dr. Halper: Yeah, so that’s what everyone always thinks about. So that we, majority of the time, close with a suture that actually goes underneath the skin. So you won’t even see it. It dissolves on its own. It’s not something where it has to be cut or removed. And the goal of that is basically to get the skin edges to come together nicely so that you don’t see anything and it hopefully heals very well. So, you know, that is, I know, the layer that everyone is most concerned with. Although for us, you know, the most important layers that we’re concerned with are the uterus and the fascia to make sure everything is nice and tight inside and no bleeding. But, yeah, skin generally, like I mentioned, underneath the skin. We don’t typically use staples. That is a very rare situation. I don’t even think I’ve ever closed the skin with staples in a C-section.

Dr. Fox: Yeah, that’s a change. When I was a, I mean, 120 years ago when I was a resident, we closed everyone with staples.

Dr. Halper: Interesting.

Dr. Fox: And then during my residency is when people started doing more of the suturing. And then I would say probably in my first 10 years in practice, it went from 95% staples to 95%-plus sutures, certainly in our hospital and probably nationally is what I would guess. I don’t know the numbers nationally, but I think most people don’t have staples anymore. I mean, you could. They’re fine. It’s just there’s slightly better results in terms of pain and cosmetic with the sutures. And since you don’t have to remove them, the staples have to remove at some point, usually before you go home from the hospital. If you remove them, the wound can open up again. That’s a little bit more likely with staples. So, there’s advantages to sutures that we like. And that’s what we do predominantly, like you said. It’s been a long, I mean, for a transverse incision, meaning from side to side, it’s I don’t, I can’t remember the last time at the staples. Same thing. Up and down incisions are a little different because they need a little bit more security, I guess. Okay, so now we’ve closed the incision. What happens at this point?

Dr. Halper: So at this point is usually when we ask the partner if they are still in the operating room or support person, whoever’s in there, to leave the room, because now, you know, the surgery is over, but also we’re, you know, cleaning things up. That’s when we see that there’s like a little bit of blood. We’re getting all those things cleaned up. That’s just, you know, not the most, I don’t know, fun part, probably for the partner to be a part of. So we’ll ask them to leave the room and we’ll get the patient cleaned up. First, we’ll put our dressing on. Usually what we do is we put what are called steri strips. It’s little pieces of tape that just help keep the skin together and cover the incision. And those usually stay on for about one to two weeks. And then we put either an abdominal pad or gauze over the incision and put like a tape over it to keep everything secure.

Dr. Fox: Yeah. And that just stays on for like a day or two. Yeah.

Dr. Halper: Exactly. And then we’ll get the patient all cleaned up and bring them to the recovery room.

Dr. Fox: With the baby. Usually.

Dr. Halper: Yes.

Dr. Fox: Yeah, unless the baby has to go to the NICU for some reason. Typically, the baby’s in the operating room till the end and goes to the recovery room with mom. And the only time that they really get, again, unless the baby has to go to the NICU, the only time they really get separated is usually the baby has to go to the nursery at some point to get, there’s an exam and they do some measurements and this or that. And so that happens at some point when mom goes to the recovery room. And that’s really the only time that they’re separate from each other. And then after that, the baby could be with mom the entire time or when, unless the mom wants the baby in there. So, you know, that’s sort of, you know, based on what’s going on in the situation. But they don’t have to be separated because of a C-section. They’re together pretty much the whole time. And also, we’re comfortable with Mom holding the baby during the latter part of the C-section. If her arms are free and she’s comfortable, she can do that. Sometimes if she’s not, you know, she’s tired or dizzy and doesn’t want to do that, the partner can do that. And, you know, once the baby’s checked out by the pediatricians, it’s not really different from a vaginal delivery. The baby just hangs out there until Mom’s ready to go out of the operating room. And then after the C-section, where does Mom go?

Dr. Halper: After the C-section, Mom will go just not even really down the hall, just across the hall to the recovery room, where she’ll stay for about two hours, typically. And that’s because you get a closer level of monitoring after surgery, just to monitor your vital signs, your heart rate, your respiratory rate, your blood pressure. Just make sure that everything is stable after surgery and you’re on a monitor bed. So you’ll still be attached to a heart monitor. Various things like that we’ll continue to monitor, you know, your urine and your pain and your bleeding just in the kind of immediate stage in a much kind of closer observational setting.

Dr. Fox: Yeah. And then at some point you go up to your room, your postpartum room, and they stay for a couple of days and then you go home hopefully. All is well. Good job.

Dr. Halper: And sometimes that’s even just 40. A lot of people will ask me how long they’ll stay in the hospital after a C-section, actually. So typically, assuming everything is straightforward, two to three days is typical. Two days if everything is perfect. Three days is totally fine, too. But usually two to three days is the norm.

Dr. Fox: Yeah. And if things aren’t perfect and someone’s recovering slower, then four days. We send you home when you’re ready.

Dr. Halper: Exactly.

Dr. Fox: And so on average, it’s about three days. So good. All right. K.I., Dr. Halper, thanks for coming on the podcast. How was it? Your first podcast here? Was it okay?

Dr. Halper: It was good. It was great.

Dr. Fox: She’s a natural.

Dr. Halper: Thank you for having me here today.

Dr. Fox: Awesome.