B (12:58)
The problem with having one kind of scale or one interpretive criteria for everybody is that it's not going to fit everyone. But could you imagine if we had a ultrasonographic scale, right? A graph for fetal growth for every single ethnicity out there? It's impossible. I mean, there's no way. And we've covered this. I think we covered it when we talked about FGR in the past. And so that's one of the limitations of what we do. And you know what? We gotta roll with it. I mean, it's just the way it is and it's not gonna change. That's just an inherent issue of the practice of medicine. I mean, people are people and then at the same time they're not because there's so many things that affect some clinical outcomes. And in this case we're talking about labor patterns. I mean, it's very well acknowledged in ACOG's guidance that maybe we should allow a little bit more time, especially in the early part of the first stage of labor, to Prevent unnecessary diagnosis of labor arrest. We get that. That's in plenty of their guidances, including first and second stage labor management, which says that using a standard labor curve for all patients is going to lead to a higher rate of intervention, AKA cesarean section and or operative vaginal delivery later on as they get ready for delivery with, without really changing any neonatal outcomes. Already patients that are overweight or obese. Oh, hold on. I guess I should say that the more politically acceptable way, which is I'm not going to get into that. But patients who are living with overweightness or living with obesity, because as we talked about before, nobody has obesity anymore, they're simply living with it. Talk amongst yourselves. Not going to get into that. But I love the term living with obesity like it's a roommate, except it doesn't pay any rent. So having a standard labor curve for everyone is not going to fit everyone appropriately. This is exactly what this new publication said. Surprise. No surprise. Now this was a retrospective study. So it's not an rct, it's not a prospective. But sometimes you have to do something like this to get all of the data at one big chunk and just to see what happens. It's okay. Even though it's retrospective, it definitely still has value. Remember we talked about its origin? This is out of the gray journals. It's accepted within the last 24 hours on 8th November 2025. Now what they did obviously is they looked at number of deliveries for those who had vaginal birth and then stratified for normal BMI, overweight and then BMI classes 1, 2 and 3. And as we talked about in the intro, there was a positive monotonic relationship in that labor deterioration. In other words, the higher the weight class and or bmi, the slower the labor progress. Direct linear correlation. As they concluded, higher body mass index was associated with slower labor progression and longer labor than in patients who had non overweight or non obese BMIs. End quote. Yeah, we've known that. Now here's the catch, okay? Here's where we're going to go. And then the answer is I'm all for it, but it's going to be very tricky because it had to be validated, this concept of using a BMI specific labor curve. So if we. So let me just say right now we don't have one. Although many, many have called for them not just overweight, but a BMI Class 1, 2 and 3 labor curve. It's just, it's not. I don't see that happening anytime soon. One Is the validation of that would be rough. Second, it's easier just to say what we currently say right now, which is please use shared decision making. Please simply allow more time, especially in that early latent phase transition dilation stage of 4-6 cm where things tend to get kind of stuck. Just allow them. Just be a little more gracious. Maybe instead of using 12 hours for a protracted latent phase, assuming everything else is held constant, maybe try to push it to 16 or the 18 as is current guidance. So it's shared decision making. Another term for that is individualized care. But as of right now, we don't have a specific labor curve. Also, as we said in the intro, could you imagine telling the patient no worries, if you were on the regular labor curve, we would have cut you hours ago. But honey, you're on the obese labor curve. You're doing just fine, girl. Yeah, that probably won't go well. All right, so. So here's what the authors say in the conclusion. Here's what the authors say in the conclusion. Quote, results. Was that too much? Yeah. Results suggest a potential need for the use of labor curves more specific tailored to body mass index when assessing progress in labor in order to avoid performance of unnecessary cesarean deliveries. End quote. Did you all get that? Results suggest a potential need for the use of labor curves tailored to bmi. In other words, BMI specific labor curves. Yes, and they are not the only ones. I know it sounds mean. It's not mean. Plenty. Plenty of data has shown this is needed. However, we don't have any high quality data on what a specific allowable labor curve for overweight or class one, two or three obesity looks like. We all know that they take longer. We all know we should be more patient as long as things look okay and there's no other issues going along. You know, if there's obviously persistent category two, just get out. That's your window to escape. If there is a severe preeclampsia and she's having a delayed labor course, perhaps get out because prolonged use of mag isn't the best either. So look to for avenues safely justified, better evidence base to try to get out. But if there isn't, be patient. We do not have high quality data on any specific alternative labor curve. Though everybody who has looked at this has called for one. So and I love this as one commentary through SMFM posted years ago when they were going back in redefining the Friedman curve with the Zang curve and of course on the original obstetrical care consensus Number one, which was safe prevention of the first C section. Quote, using a standardized labor curve for all patients can lead to a higher rate of interventions in patients who are overweight and slash or obese without having any benefit on maternal or neonatal outcome. End quote. There you go. So it sucks. It's like, man, we wish. We need to do something different. It's not right to use one scale for everybody. Okay, well, let's do it now. We can't because we don't know what that looks like. And no, we can't because it's not yet validated. Do you get that? So these are all issues here. Now, other studies have shown that maybe we're doing it wrong. Canada. And Canadian guidance through the SOGC says maybe, obviously, if PIT isn't working, maybe we do oral titrated misoprostol. That's in their guidance. Oral titrated misoprostol based on contraction frequency. That's a thing. You start maybe at 50 micrograms, and you go up by 50 micrograms every two hours until there's a set contraction pattern up to X number of dosages. That's a separate protocol of the oral titrated misoprostol. We may have an episode on that. Somebody asked recently through the show about that and asked, have you heard of this oral titrated misoprostol Dansers? Absolutely. For sure. There's data right now, most people use misoprostol Cytotec statically, which means one dose repeated every so many hours. Right. That's in the ACOG thing or orally, but it's a static dose. In other words, you know, 25 or 50 micrograms every three or four hours based on contraction frequency and tolerability. But there is an oral regimen that is progressively increasing dose, meaning titrated, based on level of contractions and uterine response. That is super safe. It totally works. It's just. Just as equivalent as oxytocin. But it hasn't really been studied in that specific population, meaning obesity. But maybe it's a thing that take. Talk amongst yourselves, maybe put that into your protocol. So there are these different ways to do this. Knowing that BMI absolutely affects the obstetrical labor curve and that higher BMI slows down, typically the latent phase once they are active. So let me be clear here, guys. I'm not saying allow more time in the active phase and be very clear. Active phase is active phase. You got to follow them rules. And active phase is active phase. Follow the rules. But for latent phase, that's where most of the data show that these patients kind of hang out, kind of stall a little bit, and then boom, they'll just turn to curve for whatever reason. Okay, so a couple of quick take homes and we're going to wrap this up. Number one, does maternal weight affect labor progress? Absolutely. And unfortunately, overweight and specifically obese patients, they just have poor outcomes, period. They tend to have more NICU admissions, lower APGAR scores, they tend to have a higher rate of C section for a variety of reasons. Not just arrest of labor, by the way. It's a variety of reasons. Fetal tolerability of labor, that's another big reason. They just tend to have higher rates of neonatal and obviously maternal issues, meaning postpartum hemorrhage, obviously preeclampsia or hypertensive disorders in pregnancy. They tend to have higher rates of intra amniotic infection or post op infections from a C section for a variety of issues. Chronic oxidative stress, bmi, poor nutrition status, the stress of labor on a patient who's not, quote, unquote, conditioned for something. All of these make sense, but it's a good reminder because it's just came out within the last 24 hours that not everything that we do, guys, not everything that we do is universally applicable to everyone. So we need to be patient. And I gotta do that myself. I'm not preaching to you guys. I'm telling myself here because I get so frustrated they're not moving. I want them to move that they get stuck. Sometimes the best thing to do is allow. Now remember, before we start wrapping this up, I'm talking about generalities, okay? So if she's a tolak, obviously you have a high level of suspicion of problems. If she has previous bad mojo from previous bad deliveries of whatever, keep that on the lookout. Always be conservative. I tell the residents, abc, abc, let's always be conservative and it will keep you honest and keep you safe. Podcast Family I think we've done what we're supposed to do. We've reviewed very quickly because I think that's our new vibe here. Try to let you know what you need to know quickly. A new publication under original research from the Gray Journal on characterizing labor progression and duration according to maternal body mass index. No surprise, nothing new. Yeah, ideally we should have a weight class specific labor curve. I don't know, maybe one day, but as of right now, we don't have it. Hey, we've got weight classes for wrestling. We've got weight classes for boxing, why not a weight class for labor? It's a pretty big darn thing that you're going to do in your life. The pretty big milestone. Maybe have a weight class for that. I don't know. Just throwing that out there. As these authors have podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Now that we've done all that, let's take it home. This has been Dr. Chapa Zobetyn, no Spin Podcast Podcast family. Thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast. It.
