Podcast appearances and mentions of fox now

Dr. Nathan Fox is a practicing OB/GYN and Maternal Fetal Medicine provider in New York City. Two of his children were also VBAC babies! He joins Meagan on the podcast today where they discuss topics in depth to help listeners make more informed decisions about their VBACs. Topics today include where to find evidence-based information, how to interpret it, the risks of uterine rupture, VBAC and COVID-19, induction, scar thickness, due dates, and third-trimester ultrasounds. Additional LinksHealthful Woman WebsiteMFM, High-Risk Pregnancy New York City WebsiteNeeded WebsiteHow to VBAC: The Ultimate Prep Course for ParentsFull Transcript under Episode Details Meagan: Hello, hello. You guys, it's November. How are we at the end of 2023? It is crazy how fast this year has gone. We have a special guest today. It's Dr. Nathan S. Fox. He is so amazing to come on today to talk to us about a couple of topics that I don't know if we've actually ever talked about on the podcast. We're going to be talking about scar thickness. We're going to talk about third-trimester ultrasounds. We're going to be talking a little bit about COVID and is it really best to induce at 39 weeks? We've had COVID. What does it mean with our placenta? We know we've been hearing it out there where our placentas are not doing well. So you guys, get ready. Buckle up. It's going to be great. I want to tell you a little bit about Nathan Fox first. He is a board-certified OB/GYN and he is also certified in MFM which is Maternal Fetal Medicine. In his clinic, he sees a lot of higher risk and unique situations. He did his residency at Mount Sinai. He has an amazing podcast that really dials in on helping people know the evidence and then also understanding the evidence in English because if you are like me, you'll know that it is kind of hard to break down some of these studies sometimes and it's hard to understand what the evidence is even saying and then how to apply it. He has this podcast and it is Healthful Woman. We are going to make sure that it is linked. You guys, he has so many incredible guests on there talking about a wide range of things. It's not VBAC-specific, but it definitely has a wide range of topics and things that you're probably going to love. Definitely check that out. We'll have it in the show notes. Dr. Fox, seriously, we are so grateful for you today. We can't wait to have you on. We'll be right back. Dr. Nathan FoxMeagan: All right, I need to pull up those questions really fast. There are a lot. Literally, we do not have to get to all of them. Dr. Fox: I'll come back if you want. Don't worry about it. Meagan: Yeah, we'll have to do a part two. You are so sweet to take the time out of your busy life, I'm sure. Dr. Fox: We are mission-aligned as they say in the fancy world. It's about getting good education, and good information out to people so they don't have to hear crazy stuff on the World Wide Web and get terrified. Meagan: Right. That's why we started this podcast even just to share stories of people who are having VBACs so people can hear and learn through those VBACs and also know it is an option and it is possible. I have a question. You said before we started recording that you have two VBAC babies. Dr. Fox: Yeah. Meagan: How was that journey as an OB and MFM? Was your wife getting information that you were like, “Wait, that's not true,” or were you like, “Actually, we need to think about this”? How was that journey as someone in the field?Dr. Fox: Full disclosure, I was getting into the field. I have four kids. My first two are twins and they were born when I was a medical student so I knew very little. I guess more than nothing, but closer to nothing than where I am now. They were born by C-section. Both of them were breech. Thank God, both of them did great. All was well. With the next one, my wife was pregnant when I was a second to third-year resident in OB/GYN. For most of her pregnancy, I was a second-year, then she was born a month after I became– not even. She was born July 17th so 16 days after starting my third year. Meagan: Right after, yeah. Dr. Fox: I knew a little bit more then. That was our first VBAC. Then my fourth was born when I was an MFM fellow. I like to say that I had kids in all of my points in training. Honestly, we didn't think much about VBAC in terms of being this grand decision and conversation. I would say mostly because the OB my wife was seeing was on board with it and didn't make it into a big deal and she was delivering at a hospital at Mount Sinai where I trained and where I now practice where VBAC is commonly done. There was a conversation about it. It wasn't like we were blind to it, but it was part of the normal culture in that hospital on the labor floor so we didn't think much about it. My wife said, “Why would I want a repeat C-section if I can try and do it vaginally?” It worked out fine, thank God for both of them. The third was also actually a forceps. We're like a textbook of obstetrics, my wife. But yeah. It wasn't dramatic. Let's put it that way, the VBAC process.Meagan: Wow. Yeah. I love hearing about it that it was just a thing. It didn't have to be a big deal. She was just going in and wanted to have a baby. She didn't want to have a C-section.Dr. Fox: Yeah, again, I think it is something that should be discussed. People should understand and not even everyone understands that it is a thing meaning people don't even realize why you wouldn't. Meagan: Why you would not, yeah. Dr. Fox: There is risk, but ultimately, if it is an option, the risk of a VBAC– again, in the right person– is not markedly higher than the risk of a C-section. So it's a conversation. Which risk would you prefer or which risk would you least prefer? So that conversation was very straightforward. “Would you want a repeat C-section? Would you want a VBAC?” She was like, “I want a VBAC.” Fine, so that was done. It wasn't like she had to meet with an attorney to go over everything and sign a waiver or anything like that which sometimes happens. Meagan: Yeah. I love hearing that. Well, I am so excited that you are here with us today. I know that we have so many questions to dive into. They're kind of all over the place. With the first one, I think a lot of our community members– we have a Facebook community, a forum, and one of the most common posts in there is looking for a provider that is supportive because they were with a provider and then they found out that the provider that was seemingly supportive is not supportive anymore. It all seems to focus around things with evidence-based information and they're getting all of the different things. One of the questions is why is it so hard to find evidence-based information on VBAC, VBAMC, and uterine rupture– because we have some providers that are saying you have a 60% chance of uterine rupture and then some saying you have a 0.4-1% chance. Those are very dramatic numbers. The range of answers is just so wide. I'm just wondering why do you think it's so hard and where can we find this information. Where would you suggest our listeners go? Let's talk about your podcast being one of those places. It's not just VBAC-specific. Your podcast isn't VBAC-specific but it's very, very good at a whole, wide range. But yeah, can we talk about where to find evidence-based information about birth in general but especially about VBAC? Dr. Fox: I mean, yeah. That's really the million-dollar question. I think that both the problem and solution are essentially that we have access to all of the information that's ever been available ever. There was a great Simpson's thing where Homer Simpson said, “Beer. The cause of and the solution to all of my problems.” Information is the same way. On the one hand, it is unbelievable how much information we have access to and that's a great thing. It's not hidden. It's not only amongst the elite that have the information. Everyone can have the same information so that's the good part. The bad part is it's very difficult to sift through all of that information and find a) what's correct or b) what's applicable to me. So for example, let's say I'm someone who has a prior C-section and I have a friend who is also someone who has a prior C-section, but one of us has a prior low transverse C-section and one of us has a prior classical C-section. How do we know that we have different percent risks? It's a high level in a certain sense. So sometimes the websites or the podcasts or whatever will spell it out for you and explain it very clearly, but other times, you just get a list like, “Okay, the risk is this, this, this, and this.” You can't really apply it appropriately. One of the things we try to do in our podcasts is to be much more user-friendly and to really explain it and what would apply to you, what wouldn't in certain situations, and what questions to ask, but I would say for people trying to find information, usually it's a shotgun approach. You Google something and find a website then find a list. You have to be very cautious and make sure that this applies to me and my unique circumstances. Hopefully, you have a doctor or a midwife who can help you with that. You might not. It's possible that you may not. The other part is sometimes, it's hard to interpret data. Understanding medical literature is a science. It's something that we train to do. We practice it. I do a weekly journal club with the OB/GYN residents. This is the top of the food chain. These are the smartest of the smart. They got into a great undergraduate. They got into medical school. They got into residency. These are really, really smart people. It's not always intuitive when you read a study or several studies on how to interpret it and apply what is and isn't applicable. It's very difficult stuff. I would say don't be dismayed if you are not understanding the information out there or seeing such variation because you are in the same boat as all of us. It's hard. It's hard to get the right information out there. Meagan: It is. Yeah. Even when I'm reading through studies or things, it's even hard for me to just understand what it's saying and what the relevance is of it and all of it, so yeah. It's really hard. I think what you said, “Don't be dismayed,” it can be really frustrating when we're out there and we're like, “Okay, I have a special scar or not a normal low, transverse incision. What does this mean for me? What does this mean for my future? What does this mean for right now?” It's really hard.I think you nailed it where one friend can have this and one friend can have this. You can both have similarities in your risks, but they also don't apply because there are other things going on in addition. Dr. Fox: There are facts like what is the truth? What is the true fact? There are always some brackets around those numbers because different studies will find different things. Let's say one study finds 1% and one study finds 4%. Is it 1? Is it 4? Is it the average of the two? Is it a range from 1-4? There are some nuances in that. But then there is also trying to sift through the interpretation of the fact. A lot of that is why sometimes you'll see different doctors feel differently about something. For example, let's say the risk of uterine rupture is– let's just do very rounded, broad numbers. Don't hold me to it. Let's say the risk of uterine rupture is 1% and if you've had two C-sections, let's say it's 2%. Let's say those are the true numbers and you can argue about those. Those are the numbers. I could describe those very differently. I could say to somebody, “All right, you've had one C-section. Your risk of rupture is 1%. You've had two. It's a little bit higher. You need to know that it's now 2%. Maybe your chance of a successful VBAC is a little bit lower.” Okay. I could say it that way or I could say, “Whoa, your risk of uterine rupture where the baby could die is doubled.” Right? Meagan: Yeah. That just gave me the chills. Dr. Fox: That's the same number. I've said the same thing in two very different ways. One person hears it and says, “It doesn't sound like a big deal. My doctor said it's fine.” Another person said, “My doctor said that my baby is going to die.” Meagan: Doubled and die, yeah. Dr. Fox: It's understandable because the doctors and midwives, people who are pregnant are all humans. Humans are complicated beings. We have emotions. We have fears. We have experiences. We have anxieties. We have all of these things that come into our heads and it colors how we view risk and how we describe it to other people. So I would say that another lesson is when you are getting information, try to differentiate the numbers and the hard facts from the interpretation of the number or the feeling about the number. That's why you always have to be very cautious when someone says increased, higher, or doubled. That's a relative risk, right? The risk of something is increased. Well, by how much? Is it increased a lot or a little? If the number was very, very low, is it still very, very low but a little bit higher?I always give people an example. If I walk across the street, there's a certain chance that someone moving a piano is going to fall on my head. If I look up every time I cross the street, I'm going to lower that risk but it doesn't matter. The risk is so low to begin with that it doesn't have any practical application to me. It's sort of the same thing. You can talk about something increasing or decreasing your risk, but if the risk is still very, very low anyway, it may not matter to the person practically. Trying to get that from a provider is sometimes difficult because they may not know themselves the actual numbers. They may just know increased or doubled or this. They may be so colored by it that they have a hard time talking about it just as numbers or vice versa. They might just give you hard numbers and you want to know how they feel about it and they're not giving it to you. It is hard, but that's one thing to try to think about or differentiate. Meagan: I love that. I love that. Okay, this can be a very political topic. Dr. Fox: Oh, all right. You're not going to mention Trump. Are we going to talk about Trump?Meagan: We are not talking about Trump. Dr. Fox: Everyone in New York talks about Trump. We like him. We hate him. We hate him. We like him. It's all we talk about. Meagan: I bet. I bet in New York, it's really hot. Maybe in New York, this is even a hot topic but we're going to talk a little bit about COVID-19. Dr. Fox: Oh okay. Meagan: We have a lot of moms who had babies during COVID-19. It was a really hard time for everyone involved. Giving birth as a provider, as a nurse, and everybody in life. This whole world of ours. Dr. Fox: It was unpleasant. Meagan: It was and that's putting it nicely, I think, in a lot of ways. Dr. Fox: I still have scars on my face from wearing my N-95 for six straight months. Meagan: I bet. I bet. It is. It was a very traumatic time. Dr. Fox: Yeah. Meagan: We're interested to see if you felt like COVID-19 had an impact on the C-section rate and if you saw more inductions happening and things like that. But right now, we have a lot of our moms being told even today, that if they had COVID-19 during their pregnancy from the time of conception to the end, they have to give birth by 39 weeks. Dr. Fox: By 39 weeks or after? Meagan: By 39 weeks. What they're being told is that their placentas will just crap out. They're just done. So it can be really hard in the VBAC community when they're being told this and then we may have a provider who doesn't want to induce. Dr. Fox: Yeah, yeah. For sure. Meagan: We have providers all over the world who are not comfortable inducing. We have VBAC moms who are like, “I want to have a VBAC. I had COVID when I was 20 weeks. I'm fine. All is well, but now I have to have a baby at 39 weeks. Here I am and my body's not doing it.” Dr. Fox: Yeah. There is a lot there to unpack. No, it's okay. You're throwing fastballs at me. I like it. You're throwing heat. I'm ready. I knew it was coming. Whether COVID increases the risk of things like the placenta crapping out so to speak is itself a controversial question. The data on that is mixed. It seems that there are some people who COVID has a negative impact on their placenta that manifests as the baby is not growing well. It can manifest as the baby getting preeclampsia. The worst-case scenario is that it can manifest as a stillbirth. However, you wouldn't expect the stillbirth to come out of nowhere. You would expect there to be multiple things leading up to it like the baby not growing well, the blood pressure going up, the fluid dropping, and a lot of things instead of a sudden stillbirth. Meagan: Right, warning signs. Dr. Fox: Now, that is different from someone with COVID who is in the midst of a very severe COVID infection. That is very dangerous to the mother and potentially the baby but we're talking about someone who got COVID and recovered or someone who just found out they had COVID and are fine, that type of thing. A) the data is questionable and B) what to do about it is also questionable. Let's say you're over the age of 35. You also have a slightly increased risk of all of those things if you had IVF. There is a whole list of things that put you at increased risk of your placenta crapping out so to speak and what to do about it is also more of a philosophical question than a hard-data question. Whether someone has to be delivered– I wouldn't say before but usually at 39 weeks– because they had COVID, I'm not doing that personally in my practice. We do follow up and do an ultrasound to make sure the baby is growing well, but if someone had COVID at 20 weeks and is otherwise doing well later in pregnancy, we don't say they need to be induced at a certain point. That's not something I'm doing. I'm not aware of anybody in professional societies like ACOG, American College of OB/GYN, or the Society for Maternal Medicine who actually recommended that or advocated that, but again, some individual doctors are very uncomfortable with any risk. I think the other part of this that is really coloring a lot of these discussions nowadays is there was a study called the ARRIVE trial that got published a few years ago. It's a very, very good study. The study was essentially designed to test if inducing everybody– these are low-risk, first-time pregnant moms. The lowest, lowest risk whether inducing everybody at 39 weeks improved outcomes or worsened outcomes. The outcome they really looked at was the death of the baby. It did not have any impact on that in either direction. What they also learned was that the rate of C-sections did not go up by getting induced. That was the biggest, I don't want to say surprised because medically, we actually thought that would happen, but in the community, that was a surprise because everyone was always told that if you get induced, you have an increased risk of C-section so the study did not show that. It showed a slightly lower risk of getting higher blood pressure which makes sense because the longer you are pregnant, the more it goes. The way I look at that study is if I want to induce someone or if a patient wants to be induced at 39 weeks, there's an upside. There's a downside, but the downside does not include an increased risk of C-section. The downside could be longer labor. It takes more time. It's not as pleasant. Okay, fine. That's how I look at the study. Some people took the study and interpreted it to say, “Since there's no risk of C-section, you should induce everyone at 39 weeks. That's the optimal thing to do.” Meagan: And it's happening a lot.Dr. Fox: Yes. There are definitely people interpreting it. I don't think it's an unreasonable interpretation because you could say, “Listen, if I'm delivering you, there's no chance for a stillbirth in the next two weeks,” I get it. But I don't think it's the only interpretation and it's also a very impractical interpretation because if you induce someone, the amount of time they are in the labor room is on average 18 hours. 12-24 hours they are in a labor room. A common labor on their own, the average is let's say 6-12 hours or something like that. So if you induce everyone, you need twice as many labor rooms. I don't think every hospital in the country plans to double their labor floor so now, you just can't do it practically. This is a very, very long answer to your question. I think what's happened is that you have a new risk factor which is COVID which is very prevalent. Everybody got COVID basically at some point and you have a new fact that inducing at 39 weeks does not seem to increase the risk of C-section so there are some people concluding, “Well, I have a risk factor, and inducing at 39 weeks isn't ‘bad' so I'm going to affirmatively recommend it on everybody.” That's tough. I don't usually recommend it. If they want it, I think it's an option but I think that that's again, hard to know when you sign up with somebody who has provided prenatal care what their philosophy is. These are questions you probably want to ask very, very early on in prenatal care. Again, the things that really matter. So for example, if it very much matters to you not to have an episiotomy, you should ask very early, “Do you perform routine episiotomies?” Most OBs these days will say no, but if your OB says, “Yeah. I do them on everybody,” and you don't want that, get the hell out. Switch. Meagan: Yeah. It's probably not your provider. Dr. Fox: Yeah, and again, if it doesn't matter to you, then don't ask that question. Or for example, let's talk specifically about VBAC. Very early on, just ask, “What are your thoughts on VBAC?” They're not going to lie to you. They're going to tell you. If they don't tell you, you're going to be able to tell right away. If they say, “VBAC is awesome. I love it. I love it when I can help someone with a VBAC. It's so satisfying. It's rewarding. There are some risks and we can talk about that. I think it's great.” Versus they could tell you, “I don't do them.” Or they say, “Yeah, I'm okay with that but I don't know.” They're telling you. They're telling you that it's okay, but they're clearly not a fan of it. Meagan: They're not gungho about it. Dr. Fox: Or the question is if they're gung-ho, you can say, “What's the culture in your hospital like?” So if they say, “I'm gung-ho, but the labor nurses think it's a stupid thing to do and the hospital is trying to get us to stop doing it because they have a lawsuit and this,” you may have a great doctor or midwife but they may be practicing in a place that isn't supportive. That's also an issue. Again, I guess there are some people who would lie to you because they “want your business”, but most OBs aren't like that because if they don't want to do it, it's because a) they think it's wrong, b) they sort of thing it's okay, but they don't want to get into a lawsuit, or c) they're just afraid. So why would they want to hide that from you? It's the opposite. They would want to tell you upfront. I think if you ask very blunt questions very early, they will tell you. If you have a provider who is uncomfortable, you don't want to be with them for your VBAC. It's not a good match. Meagan: We talk to our community members about that a lot. Don't just say, “Do you support VBAC, yes or no?” It's, “How do you feel about VBAC?” I love the question of, “What is the culture in your labor and delivery unit?” I love, love that. Dr. Fox: Usually, this is a good time when open-ended questions are best.Meagan: Yep, yeah. Dr. Fox: Let them talk. Let them cook. They will tell you their thoughts and you can read it very quickly. Meagan: Their body language, yeah. So circling back to this whole induction thing by 39 weeks, you're saying that there's not really any organization that is hard-core supporting this evidence for someone who has had COVID has to have a baby by 39 weeks. Dr. Fox: I have not heard that of anybody. Usually, if someone said that, it usually wouldn't be by 39 weeks. It's a big thing not to induce people before 39 weeks unless there is a very good reason. Meagan: Yeah, and that's what they're doing. They're inducing at 39 weeks or as soon as possible after but I don't know that anyone is recommending that specifically because of COVID. Again, I'm sure there's someone who might but I don't know. Personally, what I would do is if they had COVID, again, I would just check that everything is okay with the placenta. Usually, in later pregnancy, it's just with an ultrasound and then if everything is fine, I wouldn't. If there is a concern, then it would be based on the concern. There are people who I recommend to get induced at 39 weeks but there is a reason and COVID has not been one of them. Meagan: Okay, that's so good to know. We kind of dabbled into the ARRIVE trial. Can we talk about the 40-week mark? We have seen ever since ARRIVE came out that things have moved up. It's like 40 weeks is really 39 weeks. 41 weeks is 40. Dr. Fox: 39 is the new 40? Meagan: 39 is the new 40, yes. It seems to be happening, not everywhere, but it's happening. We talk about uterine rupture after 40 weeks. Our original 40-week, here we are, we know ACOG suggests or supports going past it, but can we talk about the risk of uterine rupture the further into pregnancy that we go?Dr. Fox: So there are two risks. Part of the reason for the shift going earlier is not because of the risk of uterine rupture. It's more of the risk of stillbirth. As you get more pregnant, if you look at just for the baby- I don't want to say this and be recorded but forget about the mom. Meagan: Let's not think about the mom. Dr. Fox: For this question, we're going to forget about the mom. Mother first, baby second but for this question, you're just looking at the health of the baby and you look at the timing of delivery. Generally, things get better and better for the baby as you get closer to 39 weeks meaning your baby born at 37 does better than at 36 weeks. A baby born at 38 does better than 37 and at 39 does generally better than 38. Once you hit 39, it plateaus and then it starts to diminish meaning that the optimal time for a baby is sometime between 39-41 weeks. As you get past that, it goes down. Part of that is because of stuff after birth like meconium or this and some of it is because some of these babies unfortunately will have stillbirths inside. That's very, very rare and I'm not saying this to scare anybody, but it happens. As you go past your due date further and further, the risk seems to go up. With that said, is it worth inducing because of that? Generally, for a typical, low-risk, healthy person, the difference between 39-41 weeks is very minuscule in terms of the baby. So I don't typically tell people that if you are low risk, then you need to be induced at 39 or 40. I tell people that 39-41 seems to be very similar for the baby or have very, very slight differences and I leave it to people's preferences. If there's someone who wants to get the hell out of pregnancy as soon as possible because they are uncomfortable and they have family coming in town or whatever it might be or they are worried about stillbirth, fine. We can go closer to 39 weeks versus if there's someone who really wants to go into labor on their own, then you wait towards 41 weeks. After 41 weeks, the risk really starts going up so there are people who– I don't really let them– I am okay with them staying past 41 weeks, but generally when we get to 42, pretty much everyone recommends inducing at 42 weeks and pretty much at 41. That's all because of the baby. Now, in that conversation for someone with VBAC, there is a second risk on top of that which is okay, that's for the baby, but what about for uterine rupture? So there doesn't seem to be a huge difference between 39, 40, or 41 weeks for uterine rupture. It's slightly higher if the baby is bigger and it's slightly higher if you induce. So you're sort of balancing, is it better to induce and have a slightly smaller baby or is it better to wait and go into labor on your own and have a slightly bigger baby also knowing that if you don't go into labor on your own, now I'm inducing with a slightly bigger baby? That's part of the risk that you may end up in a situation that is worse. And that again, there isn't a right or a wrong answer. It's a conversation. For people whose doctors or midwives won't induce them, out of principle, the hospital won't allow it, they won't allow it, then yeah. You wait as long as they will let you until it's unsafe for the baby and hope to go into labor on your own. In our practice, we do induce people with a prior C-section. It's a conversation. There are risks that are discussed. They decide, “Is it better to do it earlier? Is it better to do it later?” That's again, a conversation based on taking on all of the risks. The risk of inducing, probably ballpark adds another 1% so if your risk was 1%, it probably makes it 2%. Again, I could tell you that makes it doubled or I could tell you it makes it 2%. But you know, it increases a little bit. Not so much if they've had prior vaginal deliveries. That's more so if they've never had a vaginal delivery. The risk of waiting an extra two weeks is also probably less than 1%. These are very small numbers and I don't want to say pick your poison because neither is really poison, but whichever is sort of more palatable, that's the one you'll do. But again, you have to have someone where both options are on the table and for some people, the option to induce is not on the table. Meagan: So for someone who is really worried about uterine rupture, going to 41 weeks and maybe not getting induced or trying to go into spontaneous labor at 41 weeks, we shouldn't be feeling that we have passed that 41 weeks so our chance of uterine rupture just skyrocketed. Dr. Fox: No. The chance of uterine rupture doesn't really go up markedly the more pregnant you get. If you get induced, it goes up a little bit. You have a risk to the baby of waiting.Meagan: Or a bigger baby. Dr. Fox: But the rupture risk is not markedly changed by your gestational age of delivery. Maybe there are slight differences, but nothing crazy. Meagan: Okay, that's good to know for the audience because they ask that a lot. Dr. Fox: Right. But a lot of people or some of the doctors want a “controlled setting”. It also depends on what the situation is. Again, I practice in an area where people can usually get to the hospital very quickly if they go into labor. But if you are practicing somewhere where someone has– I actually just had someone. She actually was 2 hours away. She comes to our practice because we are a high-risk practice and she doesn't want to go somewhere local, fine. She is someone who has two prior C-sections and this. That does play into this because she's not someone who when she goes into labor is going to be monitored right away. She's 2-3 hours. Meagan: She's far away. Dr. Fox: Yeah, so that is sometimes a factor in these discussions. What you do about it depends but that may be a reason that someone might prefer to have you induced rather than going into labor on your own if they are worried about time to get to the hospital or something like that. Again, usually not relevant for me but sometimes. Meagan: More of a controlled setting.Dr. Fox: Yeah. Meagan: You have a lot of knowledge in imaging and testing and all of these things. We're going to take a little bit of a turn from due dates and all of those things and talk about tests that happen during pregnancy. This is kind of something that comes up a lot. We've got early, middle, and late tests that are happening. A couple that is happening in the early stages is genetic testing. It's becoming a lot more popular and a lot of people are wondering, does this impact my chance of VBAC at all? Does this increase my chance of Cesarean? Can genetic testing impact the mode of birth? Is there anything that you feel that our community should know about that early-on test ritual? Dr. Fox: It shouldn't. It really shouldn't impact anything about the mode of birth. For genetic testing, fortunately, if you get to the point where you are 10, 11, 12, 13 weeks when this is done whether it's a blood test or an ultrasound, if it's a screening test or an invasive test like an amnio, again, fortunately, high 90% of people have a baby with no genetic issues whatsoever, thank God. We are very fortunate. For the few people who unfortunately have a baby with one of those genetic conditions, genetic screening and testing is information. It's just to find out before birth. Now obviously, some people get results and choose to terminate pregnancies. Other people get results and choose not to terminate pregnancies. It's just information they want before birth. That's also another political discussion, obviously. But ultimately, at the end of the day, none of that really impacts the mode of delivery. Occasionally, it impacts the timing of delivery. Sometimes with certain genetic things if there are associated anomalies, then occasionally. So I don't think it really impacts. It would have to be a very rare case where genetic testing would then somehow preclude someone from a VBAC. Meagan: That they would have to have a C-section. Dr. Fox: Again, if it precludes someone from having a VBAC, it would also preclude someone from having a vaginal delivery with their first delivery. There are some abnormalities in babies where they are better off being born by C-section but then it has nothing to do with VBAC. That's just the case. But they are also pretty unusual. Even babies with certain abnormalities can usually be born vaginally safely. But occasionally, there are some that they shouldn't. But again, not specific to VBAC. That's just anybody. So yeah. I think if they want to know more about their baby's genetics, they should do it. They should feel comfortable and if for some reason, they don't want to know, fine. That's okay, too but it should not impact VBAC. Genetics is the most complicated part of all of prenatal care for patients, for doctors, for everybody. We have 6 hours of podcasting on this and it's just scratching the surface because it's complex. It is growing. It's expanding. So definitely try to get educated on that, but the short answer, it should not affect VBAC. Meagan: Yeah, it's seeming like it's growing. Dr. Fox: Huge, huge. Meagan: It's a popular topic. Dr. Fox: We know nothing more about labor than we did 100 years ago, but we know a bajillion times more about genetic testing than we did 100 years ago.Meagan: Well, and if anyone wants to find out more about genetic testing, then we will make sure to link your podcast or one of the episodes and they can filter through. Dr. Fox: Definitely, they're free. Meagan: Okay, so another one, and this is usually done through ultrasound, is the scar thickness. Dr. Fox: Mmm, yeah. Meagan: What is the evidence? What do you have to say about the scar thickness? We have some providers that are like, “Ope, it's too thin. You cannot, will not, absolutely will rupture.” They are making very big comments like that. Dr. Fox: I just did a consultation for someone on this two days ago. Well, today is Tuesday. Friday, three days ago, whatever it was. Here's the issue. When you have a C-section, you're essentially cutting open the uterus, taking out the baby, taking out the placenta, and sewing it back together. If the uterus healed perfectly, exactly the same as before you cut it open, then fine. You don't have a risk of uterine rupture any more than anyone else in the world who is having a baby. But when you cut things open and sew them back together, we know that the integrity of that tissue is always diminished compared to before. That's true in every part of the body. So when you're laboring, you are contracting and squeezing and all of that stuff, there is a chance that it would open up. Fortunately, we've learned that for people who have this low transverse type of incision, while that is true, the risk of it is pretty low– 1% or less. There are times when it is higher like if you make a different type of incision on them. So the question is are there ways to further quantify this risk or to find who is that 1%? Can we predict who that 1% is or is it just pure luck? So someone came up with an idea that, “All right. If I look at the area of the scar where I made the incision and sewed it together either before pregnancy or during pregnancy and I measure it, I can measure the thickness of the muscle.” You're taking a muscle and sewing it back together. If it's very thick, the implication is that it's stronger whereas if it is very thin, the implication is that it's weaker. I would say that is probably true that the thicker it is, the stronger it is and the thinner it is, the weaker it is, but the question is how do you use that practically? Right? Is there a cutoff where I could say, “Okay, if it's this thickness or greater, the risk of rupture is less than 1% whereas if it's this thickness and thinner, the risk is more than 1%. It's 2%. It's 5%. It's 10%. It's 50%.” The problem is that we've never been able to identify a good cutoff meaning let's say a lot of people use 2 or 3 millimeters. Under that number, it is a higher risk. If it's over that number, it's a lower risk. The problem with that is that there are enough people whose uteruses rupture despite being over 3 millimeters and there are enough people who don't rupture despite being under 3 millimeters that it doesn't seem to be any practical or useful cutoff. Most of the studies that have looked at– for example, there is a study where they said, “All right, I'm going to take 1000 women or whatever the number was who have had a prior C-section, and in half of them, I'm going to measure the thickness and do this exercise where if it's this thick, I will have them VBAC or if it's this thick, I won't have them VBAC. And then the other 500, I'm not going to even measure. I'm not going to look.” If you look at those two groups, neither one did better. It sort of indicates that this exercise of measuring the thickness of the incision doesn't seem to be fruitful. I'm sure there is somebody on Earth who you measure the thickness, you see it's then, you don't have them VBAC, and you save them a bad outcome, but there are also probably a lot of people who you then said couldn't VBAC when they would have a perfectly fine VBAC. So the short answer is that nobody knows. There isn't one standard and that is something that some people use in their practice and some people don't. In our practice, we don't formally measure the thickness and make decisions about it. If we see something that looks remarkably unusual, then we have a discussion about it. It depends on your circumstances, but we don't do that ourselves. There are those that do it. Whether they are helping the world or harming the world, I have no idea. Nobody knows. That's the problem. Now, there's a different situation where you measure the thickness before pregnancy. Meagan: That's what I was just going to ask. Is there a situation where, “Okay. We're done. We're not even pregnant and we measure.” Dr. Fox: That is something that is an emerging field of research. We do that on certain people who have had multiple C-sections. It's not often because I want to know if they should VBAC or not. It's usually if I'm worried about something called a Cesarean scar pregnancy where their pregnancy implants there or if they're at risk of uterine rupture during pregnancy. There are different cutoffs used. You have to have a very specific test called a saline sonohysterogram where we squirt water into your uterus and measure the thickness of the scar. What to do about it, you need surgery to repair that and then what do those people do in pregnancy? This is definitely not standardized and different people do it differently ranging from not doing it at all to doing it very religiously. You still don't know what is the optimal method for this. Again, we don't do this test on everybody who has had a C-section between pregnancies. We do it on certain people, but a lot of it is about planning for the pregnancy more than deciding about VBAC or not is what I would say. Meagan: If they can or cannot. Okay, that is good to know. And then in the same area, we have some people talking about adhesions. We get adhesions after we have C-sections. If we have really dense adhesions and we're having issues, does our risk– and we're seeing this on these ultrasounds– of rupture go up with adhesions? Dr. Fox: Adhesions are generally scar tissue in your belly. That's either between the uterus and other parts of your belly or between layers of your abdominal wall. Number one, we don't think that they have any impact on the risk of rupture. They make a C-section harder on your surgeon but we don't usually see them on ultrasound. That's actually not correct. Meagan: People are saying that they are told that. Dr. Fox: Adhesion just means that two things are stuck together. Meagan: It's just scar tissue, right? Dr. Fox: Yeah. It's hard to tell if two things are stuck together versus just sitting next to each other on ultrasound. If I showed you a picture of my hands together, you would have no way of knowing if they are superglued together or not unless I tried to pull them apart. So it's the same thing. On ultrasound, we rarely– sometimes, you'll see that the uterus is tilted in a really weird way and you know it must be scarred or this or that. That's also prepregnancy. During pregnancy, your uterus grows very, very large and you can't typically tell who is and who is not going to have scar tissue. It does not usually impact VBAC. Also, you rarely have a lot of scar tissue after only one or two C-sections. Usually, it's if you've had three or four or five and we're not doing VBACs on people who have had three, four, or five C-sections and no vaginal births and so it doesn't really come into play practically. Meagan: Okay, yeah. That's good to know because people are being told that in these scar thickness visits that, “Oh, and you have a lot of adhesions so your chance of rupture is increased.” Dr. Fox: Listen, I don't have the skill myself to recognize adhesions on ultrasound. I'm not sure if anyone does. I'm not sure if they're telling people that because maybe– I guess the only way you would know is say someone has had two prior C-sections and they want a VBAC and the person who did their second C-section saw a lot of scar tissue from their first C-section, then they would say, “Listen, I did your second C-section. It's a mess in there. You're not a good candidate for VBAC because if you needed an emergency C-section in labor, it would take a long time to do it.” That is a very reasonable discussion to say, “Listen, part of doing your VBAC is having the capability of doing an emergency C-section if it goes wrong or if something bad happens or there is a concern over that.” If you know in advance, I can't do a C-section easily, then it makes it more difficult. For example, that happened to someone who we know has scar tissue, or let's say someone who had multiple surgeries. Let's say someone had a tummy tuck which has a lot of scar tissue or they have Crohn's disease and they had three other surgeries. Let's say because of the size of the person themselves if they are much larger, then it is harder to do a C-section quickly, then that is a very reasonable concern over VBAC. Listen, if the VBAC goes well, great. But if I have to do a C-section in labor and I have to do it quickly, I can't do it quickly. That's sort of the reason why hospitals don't have VBACs because they're like, “Listen, we don't have an anesthesiologist 24/7. If you need a C-section, I need 30-60 minutes to get a team in place. That may not be safe.” That's one of the reasons why smaller community hospitals don't allow VBACs. It's not because they're mean. It's because they don't have the proper staffing to address an emergency. Now, anybody can have emergency labor, so it's a problem for everyone, but it's more common that if you have a prior C-section, then you may have to do something emergently. Meagan: Okay, and one of the last and most famous ultrasounds in our community is the third-trimester ultrasound to check baby's size. In our community, we have a lot of people doubting their body's ability to give birth because they are told that their babies are too large or their pelvis is too small. La dee dah, we could go on for a long time about that, or that their fluid is too low. We're getting these third-trimester ultrasounds. One, the question is, is it absolutely necessary? Can someone turn it down? Is it a bad idea to turn it down? And two, if they're told, “You're baby is too large. Your fluid is too low,” is it possible to increase their fluid somehow? Is it really possible to know exactly how big that baby is? Dr: Fox: To answer that question fully, we need more than the 5 minutes that we have left. I can come back, but the short answer is whether it's a good idea or not to have that ultrasound is debatable. In our practice, we do it but we have a higher-risk population typically. And I am pretty confident that we interpret the results appropriately. The issue isn't so much the ultrasound. It's the interpretation of it. Low fluid is a legitimate concern and that's a concern for the health of the baby because low fluid could indicate a non-functioning placenta or as we said earlier, that your placenta is crapping out. That could be a sign of that. That's real. That's legit. If the baby is measuring too small, most of them are fine, but the concern is maybe it means that your placenta is crapping out. The baby being too big, there are two issues with that. One is that, especially with big babies, they are less accurate. With smaller babies, we tend to be more accurate. Bigger babies, we tend to be more inaccurate. We may be right that the baby is big, but how big, we're not that precise. And what to do about that. Like you said, most people having a baby can deliver a big baby and everyone's going to be fine. But yes, there are risks that go up as the baby gets bigger. There is a risk of injury to the baby. There is a risk of injury to the mother and there is a risk of uterine rupture because a) the baby is bigger and b) the labor is likely going to be longer and more difficult which increases the risk. Now, whether that should be used as a criterion to prohibit VBAC, again, is debatable. There isn't a perfect answer to this. I would be less comfortable managing a VBAC if the estimated weight of the baby is 10 pounds over 8 pounds. Do I have to be so uncomfortable that I wouldn't allow it? It depends on the circumstances, obviously. It is a legitimate concern that the baby is measuring big, but again, how confident are we? Those are difficult details. Our ability to assess the size of the pelvis is even worse because the pelvis changes in labor. It's part of our assessment, but we have the humility to know that we are frequently wrong about that. It's tough. Listen, if someone had a prior C-section and their story is, “I pushed for 4 hours and this 6-pound baby didn't come out and they did a C-section,” then in the next pregnancy, I'm estimating a 10-pound baby and the pelvis does not feel so great and the baby is very high, I'm certainly a lot less gungho about it than if they said the opposite. “I pushed for 4 hours for a 10-pound baby,” in the next pregnancy, the pelvis feels really roomy and great and the baby is measuring 6 pounds. That's legitimate. I could be wrong, but that's information that might be helpful to me. But again, this has to be individualized. There isn't a perfect answer to this. I wish we could be more scientific. People have tried a lot of different things. There used to be routine X-rays and to see the size of the pelvis and the size of the baby's head. It didn't help. The baby's head changes shape in labor and the pelvis changes shape in labor so we are not precise with this, unfortunately. Meagan: No, I love that you said it's all unique. We're all individuals. We're all different and even from one baby to another, we need to remember that it's always different. Dr. Fox: Yeah. Yeah. Meagan: Well, I know that we could dive into so much more. There are so many topics, but I really wanted to just thank you so much for taking the time today. I know you've got quite the schedule and spent this hour with us answering these questions. Dr. Fox: My pleasure. Thank you for inviting me. Thanks for doing what you're doing. I think it's great and hopefully, we can continue getting people better information and making good choices. Meagan: Yes. We will make sure to link everything to your podcast and your website so people can read more about you. In New York, people can find you. Sometimes, it can be that VBAC people are looking for doctors all of the time. Dr. Fox: If you are in New York City, at our practice, we do VBACs so come on over. If we don't think it's a good idea, we'll tell you but if it's a good idea, we're on board. Meagan: And you do VBAC after two C-sections, you said? Dr. Fox: We do. It depends on the exact circumstances, but we don't prohibit it because of two C-sections. Obviously, there are some people in that category who think it is a better idea than others, but it's not a hard rule or anything like that. Meagan: Okay, good to know. Okay, well thank you so much. Have a wonderful day. Dr. Fox: You too. Thank you very much, I appreciate it.Meagan: Okay, bye. ClosingWould you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan's bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link.Support this podcast at — https://redcircle.com/the-vbac-link/donationsAdvertising Inquiries: https://redcircle.com/brands

$250,000 dollars... yes please! This weeks episode of Doin' Just Vine is a recap & all the behind the scenes juice on FOX's game show CHERRIES WILD! We cover what it was like being casted for this brand new game show? What Cherries Wild was all about? What show host Jason Biggs was really like? What are we really doing with our $73,000 dollar cash prize? And how we felt we played the game? If you haven't watched our episode yet, you can watch the replay anytime on FOX NOW or HULU. We went a little WILD that's for sure!  @cherrieswild 

A BATTLE FOR THE AMERICAN DREAM The Boxing Breakdown host, Mark Roxey catches up with Thomas "Cornflake" Lamanna ahead of his mega career match  up against  The talented and skilled 2 time world champion Erislandy Lara.Subscribe to receive episode  notification.  Listen on Apple Podcast, Google Podcast,  Spotify our anywhere you listen to your podcasts. Follow us on Instagram,  like us on Facebook and subscribe to our Youtube Channel. @theboxingbreakdown Cuban Star & WBA Super Welterweight Champion Erislandy Lara Takes on Thomas LaManna For WBA Middleweight Championship Headlining FOX PBC Fight Night & on FOX Deportes Saturday, May 1 from Dignity Health Sports Park in Carson, California  Top Mexican Featherweight Contenders Eduardo Ramírez &  Isaac Avelar Clash For Interim WBA Featherweight Title Live on FOX in Co-Main Event Kicking Off The Broadcast at 7 p.m. ET/4 p.m. PT  Primetime Action on FOX Precedes FOX Sports PBC Pay-Per-View Event Headlined By Andy Ruiz Jr. vs. Chris Arreola Heavyweight Showdown  CARSON, CALIF. (March 24, 2021) – Cuban star and WBA Super Welterweight Champion Erislandy “The American Dream” Lara will seek a third world title in a second weight class when he faces veteran contender Thomas “Cornflake” LaManna for the WBA Middleweight Title in the main event of FOX PBC Fight Night and on FOX Deportes Saturday, May 1 as part of a stacked night of boxing from Dignity Health Sports Park in Carson, California.  The broadcast begins at 7 p.m. ET/4 p.m. PT and precedes the FOX Sports PBC Pay-Per-View event headlined by former unified heavyweight world champion Andy “The Destroyer” Ruiz Jr. battling all-action heavyweight Chris “The Nightmare” Arreola, which tops a stellar boxing extravaganza.  The Belleville, New Jersey-native LaManna (30-4-1, 12 KOs) was riding an eight-fight unbeaten streak, which included seven wins plus a draw against Gabriel Bracero, before losing to Jorge Cota in January 2020. He won back-to-back middleweight fights in January and October entering this showdown, knocking out Jorge Pimentel and Juan de Jesus Gonzalez. “It's been a long time coming and now I'm finally getting my chance to accomplish my ultimate dream of becoming a champion,” said the 29-year-old LaManna. “This is the land of opportunity and I'm getting mine on May 1. I've put my heart, blood and soul into this game. I'm the definition of the ‘American dream'. People can write me off if they want, because at the end of the day, there's no doubt that I'm coming to win. This is my time.”    Viewers can live stream the PBC shows on the FOX Sports and FOX NOW apps or at FOXSports.com. Listen to all the episodes at www. roxeysportsentertainment.com#darkplaces@PBC@FoxsportsBuzzsprout - Let's get your podcast launched! Start for FREEDisclaimer: This post contains affiliate links. If you make a purchase, I may receive a commission at no extra cost to you.Support the show (https://www.patreon.com/theboxingbreakdown)

In this special hiatus episode, we plead our case as to why we believe Prodigal Son deserves a season 3. From the characters, actors/actresses, production, and those pesky but exciting cliffhangers, Prodigal Son is the show that fans need. Make sure to catch up on season 2 by watching on Hulu or the FOX Now app! Use the hashtag #RenewProdigalSon, #ProdigalSon, or #ProdigalSonSeason3 to get Prodigal Son trending on Twitter! As always, you can follow us @Call4BackupPod for all of our podcast related updates, and follow @nerdsandbeyond for the latest in nerdy news. Transcription: https://docs.google.com/document/d/1jDLGZWVq2UEZVb5EEay1DB1LYhGU-fOdds0VHCAi_fQ/edit?usp=sharing Special thanks to Megan, Julia, and Jules for their help on this episode!

Elise Go was born and raised in San Francisco and moved to Los Angeles a few years back to further live out her dream. She is an R&B/Pop singer-songwriter-producer who graduated from the Berklee College of Music. She is making a name for herself by consistently releasing her singles on Spotify and major music platforms. Check out her cool new single "Undefined"

We celebrate 250 episodes this week by going BIG! First, hear us talk to McKinley Belcher III (Anthony Carter) about this week's episode of The Passage from Fox that will tell his character's backstory. After that, it's become a milestone tradition on our show to talk about Gotham! Robin Lord Taylor (Oswald Cobblepot) joins us to talk about the final season of the show, this week's crazy episode and his fondest memory of the last 5 years. BOTH shows can also be seen on the Fox Now app! There was a TON of Batman related news, so you know we covered all of that. We also review a Star Trek crossover, dish out a spoiler filled review of Reign of the Supermen and MUCH more! Find out more about our show at www.downandnerdypodcast.com

In part 1 of 2 of our Hangover Saga, the gang talks about our favorite TV shows. We are incredibly hungover because of BHern's birthday party the night before, and we're pretty much just talking shit to each the entire time (you've been warned). We do manage to have a lot of fun and talk about a few of our favorite shows on Netflix, Hulu, Amazon, HBOGO, Fox Now and others. Check out the rest of our highly suspect, yet unusually entertaining, podcast episodes and pop culture entertainment blogs at www.popculturepodcast.com.#tvshows #streaming #hulu #netflix #amazonprime #amazon #hbogo #hbo #fox #foxnow #crackle #theoffice #parksandrec #redoaks #ozark #blackmirror #sneakypete #westworld #gameofthrones #narcos #thehandmaidstale #entourage #sopranos #thedefiantones #podcast #popculture #popculturepodcast #multipoptural #newgirl #brooklyn99 #alwayssunnyinphiladelphia #alwayssunny See acast.com/privacy for privacy and opt-out information.

On this week s episode, we re joined by Jason Schuller, a designer and maker of things for the web. His MO is always focusing on elegant simplicity, endlessly being inspired by awesome creative people, and relentlessly learning by making mistakes. Rainmaker.FM is Brought to You By Discover why 201,344 website owners trust StudioPress, the industry standard for premium WordPress themes and plugins. Launch your new site today! In this episode Brian Gardner, Lauren Mancke, and Jason Schuller discuss: The creative career of Jason Schuller Launching Press75 The decision behind the sale of Press75 The allure of side projects Prioritizing family in business decisions Creating Work/Life balance Listen to StudioPress FM below ... Download MP3Subscribe by RSSSubscribe in iTunes The Show Notes Follow Jason on Twitter Visit Jason’s Website Plasso Follow Jason on Instagram Follow Jason on Dribbble Follow Jason on Medium The Transcript The Creative Entrepreneur: Living the Dream Voiceover: Rainmaker FM. StudioPress FM is designed to help creative entrepreneurs build the foundation of a powerful digital business. Tune in weekly as StudioPress founder Brian Gardner and VP of StudioPress Lauren Mancke share their expertise on web design, strategy, and building an online platform. Lauren Mancke: On this week’s episode, we are joined by Jason Schuller to discuss being a creative entrepreneur and living the dream. Brian Gardner: Hey, everyone, welcome to StudioPress FM. I am your host, Brian Gardner. Today I’m joined as usual, with my co-host, the Vice President of StudioPress, Lauren Mancke. Lauren Mancke: Glad to be back this week again, everyone. Thank you for joining us as we continue our series on talking to members and experts of the design community. Brian Gardner: Today we have the pleasure — are joined by Jason Schuller, a designer and maker of things for the web. His MO is always focusing on elegant simplicity, endlessly being inspired by awesome creative people, and relentlessly learning by making mistakes. On top of that, Jason is a personal friend of ours, and we’re very fortunate to have him on the show. Jason, welcome. Jason Schuller: Hey, thanks guys for having me. It’s good to talk to you again. Brian Gardner: Yeah, for sure. We always like to kick off the show by asking the same question, to some degree: Who is Jason Schuller, and what is your backstory? Jason Schuller: It’s funny, I feel like “who I am” is a lifelong journey at this point. I’m 40 and still don’t know who I am. I was born just south of Seattle, out in the country, and grew up loving the outdoors. Snowboarding, mountain biking, things like that. I had a pretty typical childhood that way, here in the Pacific Northwest. I still enjoy all those things. Just love being out here and being creative out in nature. That’s me. Brian Gardner: Give us a little background then, from where you started — at least from a design and being a creative — because you weren’t always that way. As you evolved through your career it leaned that way and then you became a full-blown entrepreneur. The Creative Career of Jason Schuller Jason Schuller: The first time I realized I wanted to be a creative person … I think it’s always in you. We all know, to a certain extent, that’s in you just growing up. But I think the first time I actually realized it was in high school. I took a drafting class, and with those tools and being the perfectionist that I am — just being able to realize the design of a house and draft it out and see something I’ve made come to life. I think that was the first time I realized I wanted to do something along those lines. I always struggled in school. I’m dyslexic. I have a hard time reading books. I have a hard time with traditional learning. So drafting and becoming an architect was a struggle for me, because I wasn’t able to get through those required courses to realize that dream. That was the start and the end of wanting to be a creative person at that time. Lauren Mancke: I actually have a few dyslexic people in my family, and my dad was always concerned about that when I was growing up. I never really had an issue with that, but I can imagine that would be difficult. At what point in your career did you have creative jobs? Did you start in a normal job environment, or did you always have creative jobs? Jason Schuller: I got married really young, at the age of 23, so I was kind of forced to find a job. Because, of course, you got to pay the bills and you got to move out of your parents’ place when you get married. It’s probably a good thing. I found a job at the Boeing company here in Seattle as a technical writer, and that obviously doesn’t really get the creative juices flowing. I think it was at that time when the web really started to take off. I didn’t have any traditional training or education in web design or development, but I had an interest in it. What I started doing while I was working at Boeing was just finding websites, downloading the source code, and playing around and making things my own. Reverse engineering and learning that way. I think that’s when I really started to catch on to what you could do with the web and how I could apply my own creativity to building things for the web. Brian Gardner: So you and I and Cory Miller — another friend of ours at iThemes who we had on the show a few weeks ago — we all had this same sort of story. Where we were at our day jobs, relatively non-involved with WordPress or development or design or whatever, and we just — maybe out of lack of interest or being bored — tinkered around with WordPress and code and whatnot. You were at Boeing, I was at an architectural firm, and Cory was working in marketing at a church or something like that. Let’s talk about the beginning of your WordPress “career,” because it practically coincided with mine and Cory’s. It’s great to look back on those early days when we all had day jobs and were freelancing to start out our businesses. What stands out to you the most back then and what was the funniest part of what we did as WordPress was really beginning to evolve into something more than just a blogging platform? Jason Schuller: Just like you guys, like you said, I was working at Boeing still when I got into WordPress. Every organizational website at the Boeing company is probably still maintained using Static HTML. I was looking for a solution to that, because it seemed like a dated process for creating and maintaining websites — using Static HTML. I was poking around with Joomla, as I’m sure you did too, and WordPress came around. I immediately was drawn to it because of its simplicity. I was able to take all the website templates that Boeing had created and turn them into themes for WordPress really quickly and put together, essentially, a platform for maintaining organizational websites in the company. That’s when I really was drawn to WordPress and the potential for creating things for WordPress. That’s what spurred me into actually leaving the company, seeing that I could do much more than what I was doing. Start going off into a freelance career. I didn’t expect to sell themes at that time. I think in doing that process — leaving the company, starting doing freelance work — that’s when I saw what you guys were doing with premium themes and starting to sell themes. I think was specifically you, Brian, and Aidi with his premium news theme that he had. That’s what really got me interested in WordPress themes and potentially branching out into that market. What stands out the most was how easy it was to build a following within WordPress just getting off the ground. I went from working at the Boeing company, leaving, and within two months having a pretty strong following already in the WordPress community simply by blogging and sharing what I was learning at the time. That really stands out to me the most early in those days, is how easy it was to build that audience and that following. I think the funnest part — to follow up on that question — was meeting people like you, Brian, and Cory and Aidi, and just sharing the fun in what we were doing. Making things, designing and creating themes, releasing them, and having thousands of people consume them. That was just such an exciting time. It’s something that I had never experienced before — I’m sure you hadn’t either — sharing that camaraderie with my supposed competitors, which didn’t seem like competitors at all. I think that was the funnest part. Launching Press75 Lauren Mancke: Walk us a little bit back through the process of creating Press75. You touched on getting started with WordPress. At that time … you started in 2008, is that correct? Jason Schuller: Yeah, I got started in 2008. Lauren Mancke: Brian, you had the Revolution theme going then, but that was before you rebranded to StudioPress, right? Brian Gardner: That’s for sure. Lauren Mancke: Walk us back through the process of creating the company. You mentioned creating a following. Share with us a little bit about what made you stand out among other theme makers out there. Jason Schuller: Sure, my start in WordPress — I actually launched a blog called WPelements. I think that’s how you came to know me, through a plugin I released. Brian Gardner: Oh, the Feature Content Gallery. Lauren Mancke: I remember that plugin. Brian Gardner: Love it or hate it. Jason Schuller: Oh my god. Again, I was just blogging through WPelements, building that following. People were downloading plugins I was making and it surprised me, because I’m not a developer by trade. I’m not a designer by trade. I was just learning and putting things out there — broken or not — and people were following along. That was just the state of what WordPress was back then. It was growing so rapidly and there was such a growing community around it, it was that easy to build that audience. But again, noticing what Brian was doing, what Aidi was doing, and what Cory was doing with the premium themes, it lead me to believe that with this following I had now I could do the same thing. I think what stood me apart was finding my own niche doing something that I enjoyed doing, which was video. There weren’t too many video themes back then in 2008, so I took a stab at releasing a video-centric theme where you can embed videos and have it displayed in a nice grid. My first theme I put out there on WP Elements for $5 and it sold … it was a crazy number of copies within a couple hours. I remember going for a walk with my wife and our dog and coming back and checking the computer to see if I had sold anything, and it was something like 200 copies had been sold or something like that for $5 a piece. That’s when I realized that this could be something. It spurred me to, over the next couple months, releasing a couple more themes and then eventually building Press75 and creating a dedicated theme shop out of Press75. Brian Gardner: That’s the creative entrepreneurial dream. They say “make money while you sleep” is the big dream. You want to do that while you’re at the beach, taking a walk, or while you’re sleeping. I know when I first started selling Revolution back in the day, it was that. My favorite part of the day was when I would wake up and go to my day job and know that by then I had already made $600 or something like that. It’s part addictive, it’s part inspiring, and it’s part, “can I keep this going?” Obviously you get to that point where you have to decide, “Should I actually leave my established day job as a young, married-type of person?” We had a kid at the time, so even more so. Thankfully, Shelly had a job, and a good job at that, so it was a little bit easier for me to take off. But I think we all as entrepreneurs get to that point where we’re not sure if we should jump or not. I remember, I think it was Chris Cree or somebody told me way back then that they had been doing stuff for themselves for seven or eight years and they just haven’t looked back. When I heard that I was like, “I don’t want to not be at that spot.” Jason Schuller: Right, and I think now you can look back and say the same thing if somebody asked you. Brian Gardner: For sure. Jason Schuller: Literally, I’ve been on my own for almost nine years now, and I can’t imagine doing anything else. I can’t imagine going back to work for a company like Boeing and being in that process of a daily grind. It’s so foreign to me now. I can’t even think of going back. When anybody asks me, “Should I do it?” I always say, “Yeah, do it.” I think where we got lucky is that we did it and it worked the first time. It doesn’t always work the first time for a lot of people. Brian Gardner: All right, let’s take a quick break for an advertisement here, because at StudioPress FM, that’s how we roll. Minimalism plus warmth, a winning combination, Gallery Pro is a theme that features your gorgeous galleries and pages in a minimalist style that features stunning typography. You can make Gallery Pro your own with options for a styled portfolio, multiple column classes, a flexible front page, and full color customization. Find out more on Gallery Pro, head over to StudioPress.com/Themes. Brian and Jason s backstory Brian Gardner: All right, we’re back. Now, as I alluded to earlier, you and I created our businesses around the same time. In fact, what many folks don’t know and they’re not aware of, is that at one point you and I actually formed a partnership for a brief period, which ended not too long after it started. Now, I want us to talk about why that partnership failed. I guess failed is a harsh word, because it obviously wasn’t terrible — we’re still friends and you’re on the show and whatnot. But let’s revisit why we decided it was better to part ways, because I think a lot of people might to relate to that and it speaks to the styles of being different types of entrepreneurs. Jason Schuller: It might be different for you, actually, but for me, I think we are a lot alike in a lot of ways. I think that might have been our biggest problem as partners. We both wanted to do our own thing. We both wanted to lead the charge in what we were doing. I think when you have two partners that are so much alike in that way, it leads to problems. I know for certain the reason my marriage works so well is because my wife and I are completely different people. We balance each other out. And I think that’s true for business partnerships as well. When you have strengths and weaknesses and your partner can balance out those strengths and weaknesses with their own, I think that’s what leads to good partnerships. We were both getting started. We saw the potential, and it was just really good that we recognized so early on in our partnership — because it was only a couple months — that we wanted different things. We were able to split ways before it got dirty and go back to doing our own things. And it worked out for both of us. I’m really happy with how that panned out. I don’t regret having a partnership with you at all. I learned lessons from that, and that’s important as well. Brian Gardner: I guess it’s overdramatic because I used the word fail . I wouldn’t call it a fail. Like we said, it dissolved for very good reasons. Like you said, when you have two like-minded people, it’s tough. We just both wanted to create and do that part of it, and then no one was left to do the administrative or the marketing side of it, because all we want to do is create and move forward. I think that the lesson here is you don’t always have to work with other people. Sometimes there are great fits and there are good marriages. I know that when I merged into Copyblogger — the five of us — that was a situation where everybody brought something unique to the table and it has worked out. Our situation is sometimes when … I wouldn’t even say that the situation came between two friends, because it didn’t. We parted amicably. You did your thing. Because you had stuff you wanted to work on, and maybe it was slightly different than the direction I wanted to go. I think we both split and still continued our success, and that was good. Jason Schuller: I really see that as the beginning of me really branching out and being successful with Press75. I saw it as the beginning, not the end, for sure. It was a good experience for me. Lauren Mancke: At the time, I was curious what had happened there. I think, Brian, you had mentioned to me about this. You were using his plugin on your themes and then something happened, and I never heard what happened. So that’s fun, to hear the backstory after all these years. Brian Gardner: I was a little bit skittish back then in what I should and shouldn’t share with the public and people. It’s different than it is now. Even when Revolution — StudioPress rebranded from Revolution because of a cease and desist letter, and I got squirrelly because I was new to this. I did a lot of, “Well, it was the best thing, the great decision.” I didn’t do a lot of backstories because back then I was less into transparency and authenticity than I am now. Now I think I’m more that way because I want other people to learn from the stuff that I’ve gone through. Back then it was all new and I didn’t have any real knowledge to share other than, “This is weird, so let’s not talk about it.” Jason Schuller: Right. I think I was the same way. You get full of yourself a little bit. You definitely don’t want to share those lessons because you’re not — it’s not apparently clear what the lesson is back then when you’re going through it. It takes sometimes a couple of years to look back, reflect, and realize who you were back then and how you want to be now. The Decision Behind the Sale of Press75 Lauren Mancke: Let’s continue in that vein, Jason. What are some of the biggest challenges that you’ve faced with your company, Press75? I know we had a chance to talk at Circles Conference about some of the reasons you decided to sell it, and you’ve also shared with some others about your frustrations with WordPress in general. Can you give our listeners a bit of a behind the scenes on the decision to sell? And did any of the frustrations you’ve had with WordPress affect that decision? Jason Schuller: Yeah. There’s a couple of factors that went into me wanting to sell Press75. I think the biggest challenge, first of all, of running Press75, was trying to stay true to myself and not giving in to the appeal of doing everything that everybody else was doing at the time. I think that was my biggest struggle. I built Press75 on my own style and my own way of doing things, and that’s what made it so popular. I fell into that trap after a while of noticing what everybody else was doing and wanting to do the same thing. Wanting to grow it beyond what it was. That was one of my biggest struggles. The second side to that is the direction WordPress was taking after a while. I think it was around 2010-2011 that WordPress really started to get, in my eyes anyways, pretty bloated compared to what it was in previous years. It was this perfect, simple, content management system that was easy to build themes for, and it became this massive CMS for doing pretty much anything you wanted to do with it. With that came the responsibility in creating themes that people wanted. What people wanted was basically all the functionality that WordPress provided, plus all the functionality that every plugin available for WordPress provided. That’s where I started to disconnect a little bit. I wanted to continue doing my own thing, which is minimalist, simple design, and it wasn’t jiving with what the market wanted at the time, which was everything under the sun. That’s what really led me to go down the path of looking for a new owner for Press75 and wanting to do something different. Brian Gardner: We had Cory on the show, as I mentioned earlier. He and I and Lauren discussed something very important and something that still is under-discussed, I think, in the entrepreneurial space, and that’s all about mental health. Specifically, how it pertains to being an entrepreneur. Now, after selling Press75 during the summer of 2014, I know you went through a pretty rough time trying to process the end of that and what would be next. You went through a period of time … To whatever extent you feel comfortable, can you just talk about that a little bit? What went through your head and some of the emotions and things that were going on after the sale and before you started the next few projects? Jason Schuller: Sure. Yeah, that was definitely a depressing couple of years for a lot of reasons. I think, primarily, when you’re in that game of building something and it’s successful — it’s the first thing you’ve done and it became a success really quickly — you have this attitude that everything you do in the future is going to be successful just like the previous thing. I kind of had that attitude getting out of Press75, thinking that whatever I did next was going to take off and be successful. It just wasn’t the case. That was a big lesson for me to learn. But with that came a lot of depression. I can definitely say that I was the most depressed in my life — from the standpoint of my professional career — than I’ve ever been. But it was twofold, because in my personal life, my little girl had just been born in 2013. Personally, I was on a high. Professionally, I was on a low. Those two were just clashing in the middle all the time, because I had this great need to provide for my family, but I couldn’t figure out how to do it. Learning that lesson that maybe I’m not as special as I thought I was and that not everything I create is going to be instantly a success. Looking back on that, it was extremely important for me to go through that period of a reality check almost, and realize that creating successful businesses takes more work than you actually might think. It’s going to be harder the next time around, even though I have had a previous success. That’s where I am today. And that’s when I started opening up to new opportunities of maybe joining a team or working under the umbrella of another company and seeing what that opportunity has in store for me. That’s when I joined up with Drew Wilson and Plasso. I feel like I’ve grown so much more since doing that. It was an important step for me to take. The Allure of Side Projects Lauren Mancke: You’ve also been working on a number of projects like Droplets and Pickle and Atmospheric. Can you talk a little bit about those and what made you decided to do each one of those? Jason Schuller: I think Brian can relate to side projects and wanting to do everything that pops into your head. Maybe I get a little bit less focused than Brian in that way. It’s one of the things I enjoy most, is doing side projects. But it’s also a big drawback for me as well, because it distracts me from doing the things that I should be doing. I take on these side projects. I want to see something come to life and I put it out there. Then as soon as it’s out there, I lose interest. The process of building them, giving it my all and making something work, I think that’s really a healthy thing. But putting it out there and just letting it just go stale, that’s not so healthy. I’ve been trying to learn for myself and my own sanity to focus on important things and not give in to doing everything that pops into my head. Side projects — they’re kind of a double-edged sword for me. Brian Gardner: I for sure relate to the whole, “Have an idea, carry it out, and launch it” type of thing. I’ve had to be very specific with what I do as a “completely outside of the scope of my job” thing. I’ve only got one thing that I do there. But from a creative standpoint or from a design standpoint, I get inspirations left and right all the time. I’m always in my own head thinking, “Ah, I’ve got this great idea.” Even if it’s an idea of something I would do as a true side project, I try to channel it away and say, “That’s not the right time to actually pursue a actual side project,” but conceptually take what you’re envisioning and wrap that into something that then can become a theme that we sell on StudioPress. Some of the things that I’ve done lately have been the ideas or creative endeavors that I wished to live out, but just dial back the execution part and say “Okay, well at least I’ve put forth some time and effort and energy into something that a) is part of my job, and then b) something that hundreds or thousands of people can benefit from and they do.” Jason Schuller: I’m starting to do that same thing. It feels good to be able to refocus that energy in a different way that makes it available right away under what you’re supposed to be doing. Again, I’m working under Plasso right now and designing and making things for Plasso, so every time I have an idea I’ve been exactly doing what you’re saying, rechanneling that energy into something that maybe could work for Plasso. That seems to be panning out for me, because I can use that energy still and not let it go away. Prioritizing Family in Business Decisions Brian Gardner: We talked about some of the stuff you did at Boeing. That worked its way into WordPress and Press75. Then you sold that and you’ve had some of these fun side projects. Some have and haven’t been included or involved with WordPress. And then you’re doing work with Plasso. But there’s more to you than that, though. I know that because I’m a friend of yours, but also because I follow your Instagram feed, which is a total window into the world outside of Jason as the guy who sits in front of a computer and does design and software and creativity stuff. From the conversations you and I have had over the years, I know that the definition of life for you far exceeds running a business and being a successful entrepreneur. I can think of two things — or shall I say two people — that matter to you more than anything. I’m guessing I’m right here. Jason Schuller: Oh yeah, absolutely. The ability to be home with my family, my wife and my daughter, and be with them more than I actually work has been the biggest gift of my life. Again, I can’t imagine going back to working for that company eight hours a day and not seeing my daughter. Only seeing her in mornings and at night. It’s not anything I can even fathom at this point. This experience is something I’ll cherish forever. It’s actually my biggest motivator in life to keep doing what I do. To be creative, to keep pushing, and to keep learning and growing and stay relevant, so that I can maintain that lifestyle that I like so much now at this point. Because I want to maintain being able to spend as much time with my family as I can. Brian Gardner: We talked to Brian and Jennifer Bourn a few weeks back about maintaining a work/life balance, because they spend a lot of time with their kids traveling and doing things like that. From my perspective from the outside, even though I know that personally you were going through some rough times, to see you post pictures or to talk about — even in the context of a sentence — just saying, “This is my dream. This is my world. Spending time with my daughter and watching her grow up.” From my perspective as a dad, it’s awesome. It’s great to see. And it’s also convicting, because sometimes I don’t feel like I have that much of a conviction to be that intentional about spending time with Zach and Shelly and stuff like that. I’m around a lot. I’m here all day when he’s here. I send him off to school. I’m home when he gets home. But it’s a lesson and a great motivator, like you said, to maintain that. Because once you have that … Of course, things will change as she gets older. Because he’s 12 now and he doesn’t want anything to do with me anymore sometimes, and I’m like, “Okay.” Then you think, “A few more years, he’s going to be out of high school.” I look at Shelly and I’m like, “What are we going to be doing all day long now?” There’s that to consider. But you still have plenty of time left with her. Creating Work/Life Balance Jason Schuller: I look back at those couple of years where I was super depressed from a professional standpoint but just living the high life from personal standpoint … I don’t know, I just have to believe that maybe that’s way it was supposed to be. For me to be there 100 percent for my kid those first couple of years that she was growing up and becoming a person, I think that that was such a special time. I reflect and think of it that way, instead of, “Oh, I was just super depressed all the time from a professional standpoint.” I look back at it — at those pictures, all those videos, and all of those trips that we took together — and remember it that way, as the time I got to spend with my daughter growing up. Brian Gardner: Let’s talk to Lauren. Lauren, how do you feel about the fact that you’ve been able to spend a couple years with Fox? Now you’ve got two more coming, and I don’t know if being home will actually be a good thing for you or not with all the distractions and whatnot. Lauren Mancke: I actually was going to chime in. I think that’s one of the things I bonded with Jason over when we first met, was that family-first mentality. We discussed making business decisions based on that. Putting your family first and creating a work/life balance that gives you the opportunity to be home with your children. I think it’s really important. I heard, Jason, that you’ve got a pretty sweet setup for working from home. Brian’s actually mentioned it on another episode. I haven’t been able to set up my super sweet office yet, but I’ve got schemes and I’ve got visions. What is your favorite part of working remotely and working from home? Jason Schuller: I think you have to make a creative space for yourself. Something that inspires you every day. Somewhere you want to actually sit and spend a good amount of time in, so that you can let those creative juices flow. For me it was building this office. It’s literally just a little room on top of my separated garage. I built it in 2009, I designed it myself. My father in-law and I built it together from the ground up. Now it’s just that space I get to go to every single day and enjoy the view from my office and just be creative. It’s quiet and it’s peaceful. I think it’s really important for us when we work at home to have that space that you can go to and feel that way and just work. Brian Gardner: See, I don’t think I have that. Mine’s called Starbucks. I just rent that space, $6 a day. My office isn’t anything special. I’ve actually had — I still probably won’t do this, because it just would cost too much and it would be silly — but I had this vision of designing the office that I have into a Starbucks. I have a friend of mine who his friend is actually one of the guys who architects and engineers the refurbishment of Starbucks. I was actually going to hire him and say, “Come into my room and do Starbucks stuff.” I was going to put a little live-edged countertop. Put in the floor and some lighting. Really try to emulate a Starbucks. Then I just realized that was probably money not well spent. But I do, I see the pictures of your office. It overlooks the lake there, and you’re always posting pictures of the mountains. “Then I took a quick drive up to go mountain biking.” There are people in this world — you are one of them, Jeff Sheldon is another — who I really have envy over their lifestyle and their ability to connect in places that I don’t live near. So good for you, that you get to have that type of space. Jason Schuller: Yeah, man, I really love living here. I can’t imagine living anywhere else. I’m sure there are plenty of better places to live than Seattle, but I grew up here. I love it. I love being connected to the mountains and nature in general, and being able to do that pretty much within 20 minutes of my place. It’s super important for me to maintain. So yeah, I love it. Brian Gardner: As we wrap this up, we asked Bill Kenney a few weeks ago — from Focus Lab — the same question. I want to do the same with you, because I got a feeling it might be a little bit different answer. I think it’s really important for our listeners to get different points of view, so here it goes: If you had a chance to speak to a group of young designers or creatives and your presentation was limited to five minutes, what would you say to them? Jason Schuller: Wow. That’s a loaded question. Just drawing from my own experience, I think the most important thing, for me anyways, is moving forward. Is not to forget who I am and what I do, because that’s what lead me down a bad path when I was doing Press75, was paying too much attention to what everybody else was doing and trying to emulate that. When I really sat back and did my own thing and did it in my own way, that’s when I was most successful. That’s the most important point for me. Also, making yourself a little uncomfortable at times. I got really comfortable during those years of building WordPress themes. Living that life for a couple years really didn’t challenge me all that much. I’ve noticed this last year of working for Plasso — being with a team and being challenged on a level that I’ve never been challenged before — I’ve grown so much as a person. As a creative person, as a designer, and as a developer. I don’t think I would be where I am now without that continual challenge. I think getting yourself uncomfortable is also a big lesson that you need to keep in mind as you move forward. Brian Gardner: That’s a great answer. Lauren Mancke: That is a great answer. Is there anything else you want to add before we wrap this thing up? Jason Schuller: No, man, I can’t think of anything. It’s been a pleasure talking to you guys, and I wish I could chat with you more often. Brian Gardner: We can make that happen. Whether it’s on the show or not. Jason Schuller: I miss those WordCamps. I’m not in that WordPress scene anymore, but that was the best part of those WordCamps, coming together. Skipping all the presentations and sitting in those halls and chatting with guys like you. People that were doing the same thing. Brian Gardner: I will say this, Circles Conference, for me, has become the new WordCamp thing. I realized I’m more of a creative than I am a WordPress guy, even though I create WordPress products. I love WordPress and I’m so thankful for what it’s done for my life, but I realized my hardcore passion is about creativity. I will say, there was an empty spot in my heart this past year because both of you guys left me. We had the luxury of being together both — all three of us, actually — last year, and I missed both of you there this year. Hopefully next year maybe we can try it again. Jason Schuller: Oh yeah, I’ll be there next year for sure. Lauren Mancke: I won’t be pregnant. Jason Schuller: But you’ll have three kids running around. Lauren Mancke: Yeah. Brian Gardner: Will’s a soldier, he can handle it, right? Lauren Mancke: He’s got this. Brian Gardner: Well, Jason, thank you so much for being on the show. Thanks for being a good friend to us at StudioPress — to Lauren and I — and we look forward to seeing what you come up with next. Jason Schuller: Thank you.

Josh and Melissa discuss Grease LIVE! the FOX event. You can catch up on the FOX NOW app if you missed it. 

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