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- [00:01]
A
This episode is brought to you by Disney. This Thanksgiving, Judy Hopps and Nick Wilde are back on the big screen. So grab your family and friends as Disney invites you to return to Zootopia for the fur nominal movie event of the holiday season. See all your favorite Zootopia characters, plus new favorites in the most paw eomet movie of the year. Don't miss Disney Zootopia 2 when it hits theaters everywhere November 26th. Get your tickets now.
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B
It's interesting in medicine that we have kind of universal scales or universal criteria for things. You know, diagnostic checkboxes that we apply universally to everyone. And in the vast majority of cases, that makes sense. I mean, people are people. Whether you are in the Northeast, whether you're in the south, whether you're in Canada, whether you're in Australia, whether you're in the U.S. it doesn't matter. I mean, there are some things that are pretty universal, but there's other criteria or other management guides that sometimes just don't fit everybody.
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C
One size fits all. Who are they kidding?
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B
There are two things in obstetrics that honestly we apply probably incorrectly to everyone. And the truth is that's probably okay because there's no way to make a curve for. For every specific group of people. Let me explain these two areas and why one size doesn't always fit all.
- [01:37]
C
One size fits all. Who are they kidding?
- [01:40]
B
First of all, let's do the labor curve, which is our main focus, because we have one labor curve. Of course, we have the new and revised version because nobody uses the old Friedman curve, which held the mark right. It held the bench as the de facto labor management of centimeter change per hour, whether your nullip or primeip for the first stage of labor. And the second stage of labor that was the de facto answer is a Friedman curve. We no longer use that. We know that was very rigid. So now we use the updated labor management, and that's fine. But that one labor curve is applied to everybody, regardless of one big factor that we know affects labor progression, and that is a patient's weight.
- [02:27]
C
One size fits all. Who are they kidding?
- [02:31]
B
Now, here's. It's tricky. It's tricky because could you imagine. Could you imagine us talking to a patient and going, oh, hey, welcome to labor and delivery? Well, based on the normal BMI weight curve, this is what we're going to use. Or the opposite. Well, based on the obesity BMI labor curve, here's what we're going to use. I mean, that'd be kind of a little offensive, wouldn't it? But maybe actually it makes sense. So that's what we're going to talk about because there's a new publication that just came out of the gray Journal, that's the American Journal of Ob gyn. This just got released ahead of print. It's not even officially out yet on the 8th of November, 2025. I realized in the last episode, I think I said something right off print. I think we recorded that on the 6th of November. Is that right? Yeah, on the 6th of November. And I said, this just came out on October 5th. Well, it was actually supposed to be November 5th, but nobody caught that. So that went out live. Anyway, the idea is we tried to let you know what is really hot, really fresh off print, typically ideally within 48 or 72 hours. Sometimes we get it in within the week. I think that's pretty good. But this actually came out on November 8, 2025, and we are recording this on November 9, 2025. It'll either come out on the 9th or the 10th. I don't know. Depends on when we finish and when we decide to send it out. But nonetheless, the idea is we try to tell you what's out in print quickly. This is a brand new study, the title of which is Characterizing Labor Progression and Duration According to Maternal Body Mass Index. Now, as we've said many times before, nothing new under the sun. So if you're saying. Wait a minute, wait. BMI Effects Labor Curve. I've never heard that. Wow. Wow. I mean, that means you're just brand new in the practice, because we've known for about 40 years that labor is affected by BMI. But here's the question, here's a proposal, as these authors are also asking, why are we applying one graph to everybody when it doesn't fit everybody?
- [04:41]
C
One size fits all. Who are they kidding?
- [04:44]
B
The other part of obstetrics, where we apply kind of one scale to everyone, what do y' all think? Come on, man. We've talked about this, especially in our patients. Now, this applies specifically to our patient population because we love our patient population. We love who we care for. We want to be the safety net for our community. And so we take care of patients who are pretty darn high risk. It's what we do. And so in this population, we have a lot of people who also come to us for delivery from outside of the U.S. for example, El Salvador and Guatemala. Now, genetically and in general, just a generality. Don't send me something ugly, though. You know, this is true. A tribal Guatemalan patient, which we have many. And Peruvian. I mean, they're just fascinating. What a great culture. Cultures. They come and they're about five feet tall. Do y' all get where I'm going here? So, of course, every mom, every patient that we get, who we ultrasound, their child looks growth restricted. Why? Because the original Hadlock formula was based on primarily Europeans who are a lot taller than tribal Guatemalans.
- [05:57]
C
One size fits all. Who are they kidding?
- [06:00]
B
The problem with that is that when their children look under 10 percentile, we do umbilical artery dopplers. We have to do antepartum fetal surveillance. We follow late preterm early term induction based on guidelines. And so we do all this extra intervention, although, most likely. Although we can't distinguish pathological from constitutional, most likely their children are very small because of a constitutional genetic issue. And I see both parents. Guys, look, who am I talking? Just FYI, if you don't know, I'm 5, 2, 53 with my boots on. All right? I take off the boots. It's like an elevator going down. So I get it. I get the short stature issue. My poor daughter, she got the choppa jeans because she's like five foot tall. God bless her. She's also a beast at sports, just FYI. A beast. Anyway, I digress. What am I doing? Oh, so, yes. So we've got two things that we universally apply. Thank you. That we universally apply to everyone incorrectly. A universal labor curve and a universal ultrasound for fetal weight.
- [07:10]
C
One size fits all. Who are they kidding?
- [07:13]
B
So that's where we're going. We're going to tackle something that was just released ahead of print on November 8, 2025. We're doing this the next day, November 9, 2025. And we'll see. We're trying to finish this today. If not, we'll finish tomorrow. I'm pretty sure we'll finish today. But this study aimed to look at this again. Again, I'm not going to belabor this because. And we're going to be out of the intro. It. If this is news to you, you got to read more. You got to read more because every piece of literature has said this. Every piece of data has shown this very thing. Again, nothing new under the sun. Why are we covering this? Is it mind blowing new information? No, but. But it is three things. Number one, a great reminder that what we apply to everybody doesn't always fit. Number two, to allow more time, especially, especially in the latent phase transitional dilation interval. The latent phase transition dilation interval. You know what that is? That's between four and six. Between four and six. Right before they pass that hump, they get around that band, they go around that corner. Whatever other analogy you want to use, be patient. Because when you think they're about to stall out, boom. They typically tend to go, yeah. And we know this. There is a direction linear correlation between weight and labor deterioration. Let me say that again. A direct linear deterioration in labor progress directly related to increasing levels of bmi. Okay, so we get this. This is nothing new. Nothing new. But. But that's a good reminder for us to maybe be a little patient. And guys, I'm very, very by the book. I'm very narrow. If they start falling off, I am like, we got to get out. Although, remember that we try not to do a C section in the latent phase just for slow progress unless the criteria has been met. At least 12 to 8 hours ruptured with some kind of stimulation to get them moving. So that we don't do unnecessary cesarean section. That's in the management of first and second stage of labor from the college. SMFM agrees. Just be patient. Allowing up to 18 hours or more. It actually says you can do individualized care after that, although you risk, of course, IAI and the chance that it's going to happen starts to decrease per hour after that. But prolonged latent phase or protracted latent phase, 12 to 18 hours with membranes ruptured and stimulation and they're just not moving. It is reasonable to say we've got protraction here. However, one thing that we need to take into account is the patient's BMI is the patient's bmi. So we're gonna talk about this. Cause the terms that these authors use. I can't believe I'm giving away all this. I'm still in the intro. Should we stop? Let me just give you this one term and then we're going to be done. The term that they use, and I love it, is this. It's such a statistical way of saying direct linear correlation. Why don't we just say direct linear correlation? It's the exact damn same thing. But no, they've got to go with a positive monotonic pattern. A positive monotonic pattern was observed. Yes, well, that is true. That also means a direct one to one kind of correlation. I love it. I love it. You got to use all. Look, you got to use all of your $10 words when you're doing a manuscript, because that's what it's for. It just makes the point that one labor curve doesn't always fit everybody.
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C
One size fits all. Who are they kidding?
- [10:41]
B
I think I've set it up enough. I think I'm getting myself into trouble. Let's get out of here. And then when we come back, I'm going to briefly review this publication because again, nothing new. And then we're going to talk about has there been a proposal for for a BMI specific labor curve? What does that look like? Or what doesn't it look like? Cuz it doesn't exist. We'll be right back. This is Dr. Chapa's OBGYN no Spin Podcast.
- [11:56]
D
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- [11:57]
B
I can never find anything in my size.
- [12:00]
D
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- [12:13]
B
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- [12:16]
D
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- [12:25]
E
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- [12:58]
B
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.