Loading summary
Transcript10 lines
- [00:01]
Dr. Chapa
So good, so good, so good. Score. Holiday gifts.
- [00:05]
Commercial Announcer
Everyone wants for way less at your Nordstrom Rack store. Save on Ugg, Nike, Rag and Bone, Vince Frame, Kurt Geiger, London and more.
- [00:13]
Sponsor Announcer
Cause there's always something new.
- [00:14]
Commercial Announcer
I'm giving all the gifts this year.
- [00:16]
Dr. Chapa
With that extra 5% off when I use my Nordstrom credit card.
- [00:20]
Commercial Announcer
Santa who join the Nordy Club at Nordstrom Rack to unlock our best deals. It's easy. Big gifts, big perks. That's why you rack Ford BlueCruise hands free. Highway driving takes the work out of being behind the wheel, allowing you to relax and reconnect while also staying in control. Enjoy the drive in BlueCruise enabled vehicles like the F150 Explorer and Mustang Mach E available feature on equipped vehicles terms apply. Does not replace safe driving. See Ford.com BlueCruise for more details.
- [01:07]
Dr. Chapa
I'll get the lubricant. There's no time for lubricant. There's always job. A lubricant Podcast Family in this episode we're going to examine, we're going to tackle a not uncommon situation. If you do obstetrics, remember, obstetrics is our main vibe. Even though, even though we do occasionally. Well, not occasionally, more than occasionally, shows some love to gynecological topics and reproductive endocrinology. But obstetrics is where it's at for us. So here's the situation. The patient got to second stage. She's right there. She's about to deliver. That fetal head is just about or is crowning. In other words, we're at plus four or plus five and it just won't clear that introidal or perineal skin. So what do you do? Well, of course you grab some lube. Well then try axle grease. The idea of lubing the head out sounds good. I mean, after all, doesn't that make sense? What do you do to a ring on your finger that you can't take off? Well, you put a little lube on that. What do you do with a screw that won't unscrew? Well, you put a little bit of lubrication on that. And so the point is made. So traditionally, either baby shampoo or some kind of water soluble gel gets all coated on the baby's head because we're going to just gel that kid out of that vagina. I'll get the lubricant. There's no time for lubricant. There's always time for lubricant. The question is though, is that anecdotal practice or Is that actually evidence based? Is there data for this? So we're going to do, in this episode, we're going to examine two meta analyses that actually came up with different conclusions. However, in this episode, we are going to explain why one of those meta analyses probably should be trusted more than the other. So we're going to tackle lube it up to get that kid out. Does that work? Listen in for details. This is Dr. Chapa's obgyn no spin podcast. Podcast family. Well, in typical fashion, real world situations become inspirations for the show. This is my week of night call. And on one of these nights, on call, in the middle of the night, we had a patient who was at second stage of labor. Baby was right there at plus 5, but she had already developed intra amniotic infection IAI. During that second stage, we ordered the appropriate antibody antibiotics, gave her IV fluid hydration, but the baby has now gone to one hundred and sixty to one hundred and seventy because of the IAI and maternal temperature rise. So I look at the resident and I'm like, look, it's having typical second stage D cells. Baby now has tachycardia. It's persisting category two. We're right there at plus five and it's not happening. Let's get an outlet and just facilitate delivery. Resident said, yeah, no problem. Great. So as I turn around to open up the vacuum to hand it to the resident, I see copious baby shampoo lube cord all over the baby's head and the introitus. What are you doing? So I was like, wait, hey, hey, what's going on? What are we doing? And so his answer, very innocently enough, was, well, I was trying to lube it out so that we hopefully don't have to do a vacuum because it's right there. To which I said, well, that sounds great. The problem is if it doesn't come out and it hasn't, and we now try to do the vacuum, it's pretty darn hard to create tension and a suction vacuum with a bunch of lube and shampoo all over the baby's head. What are you doing? Yeah, well, it didn't deliver, so we had to wipe off the excess soap and finally did apply the vacuum. And it was a simple outlet vacuum. But all to say is that made the great discussion of brother, what is the data? Show me the evidence that lubing it up for delivery actually is a thing. And very honest. He said, wait, there's no data for that. Well, that led to this. What are you doing? Yeah, that led to this episode and that's why we are here. So it's interesting because lube in, in the vaginal area, slash. Perineum has been looked at in, in two ways, guys, right? The first way has been looked at for the prevention of perineal trauma with the idea that lubricated tissue, because there's less friction forces, are less likely to tear. And I gotta be honest, hey, there is some data for that. It's con. It's a little conflicting, but, but it still favors the trend is that perineal massage with lubrication at second stage, or ideally even before labor, like at 36 or 37 weeks to prepare for labor can relax the pelvic floor muscles, the ischiocavernosis, superior transverse perineal muscles, bulbocavernosis muscles, all of that stuff right at the introitus, that ug diaphragm, all of that can be loosened with massage. So if they're not going to do it antepartum, then beginning that second stage with a little bit of lubrication, especially on the superficial transverse peroneal muscles and the bulbo cavernosus muscles, yes, you can ideally reduce some perineal trauma. Even third and fourth degree lacks. Now that data has held true primarily in no lip parish patients. All right, once I've had a test of the vagina, test of passage, then typically that recall and that muscle laxity still stays there to some degree, although some of that can be recouped with Kegel exercises. However, if there's a long inter delivery interval, like you know, five years or so, then even though they're not in oliparis, perineal massage again could be considered because it's been such a long time since the last delivery. So yes, there is data where perineal massage and lubricant at the second stage, or once again ideally antepartum before labor begins can reduce some perineal trauma. That is a thing. Okay, but that's not really what we're going to talk about because our focus here is on lubing that kid up, grease it up so that he can slide out of the vagina like a slip and slide. Well, then try axle grease. Well, is that a thing? Well, let's take a look at the data and we're going to cover this rather than looking at individual studies, we're going to do systematic reviews and meta analyses because there's two that are relatively recent and the most recent One was in 2023. I'm sorry, 2022. And then the previous one was in 2019. So again, not long ago. And they have conflicting answers here. So I found this very interesting. So we're going to start as we walk down the timeline. First in 2019, in the Journal Maternal, Fetal and Neonatal medicine. That was December 2019. And then we'll jump ahead to 2022, where the second meta analysis was done. This one was in the Journal of Obstetrics and Gynecology Research. Two different systematic reviews separated in time by three to four years with two different results. However, one of these systematic reviews should be trusted more than the other. And that's not me saying that. I'm not being mean. The authors themselves, that quote, less trustworthy. End quote. Meta analysis tell you, they're like, hey, FYI, I told you what I found, but interpret it with caution because of this. And I'm explaining that here in a minute. Okay? So while there is some benefit, there has been some benefit to perineal massage for perineal trauma. That's not our focus here, okay? Our focus is on lubing the kid up to slide that kid out like a slip and slide. In 2019, the first systematic review on this, which we're gonna cover, was published. And I chose that one because, again, it's still relatively recent. And I thought it was very well done because they were very strict in their criteria. Of the studies that went in for this review, this was only three RCTs. Three RCTs. When we jump ahead to 2022, we're gonna talk about the second study, systematic review and meta analysis, that used 19 trials. So when you're less stringent of the criteria and the studies that you use, that that's gonna affect some of your results that make sense. So super tight, super strict criteria, you end up with three RCTs. Now, what was interesting is that in these studies, which a total N was only 512. Okay. The total study of participants here grouped together was 512. They included studies that used lubrication starting in the first stage of labor. Like, oh, hey, you're 4 centimeters, you're 6 centimeters, now you're 7 centimeters. And they applied lube. They lubed up the vagina starting in the. The first stage of labor. Oh, I don't want to critique somebody else's study or their design, but that's kind of weird. I mean, why would you do it? It's going to leak out. And again, it's not like a pipe that you're trying to put in another pipe into or a fitting that you got to keep lubing that up you, if you're going to do it, you'd figure that you would do it at second stage. But hey, what do I know? All trials used water soluble gel and they used about 2 to 5mls for each vaginal examination. Now that's different, okay? This is different than just a little bit of, you know, lube on your finger, you know, to do the cervical exam. This is purposely for the. For the purpose. Purposely for the purpose. Oh, Lord have mercy. See, I'm on nights, I'm telling you guys, this is what happens when you do this post call. They put lube in the vagina, not just as lubrication for the cervical exam. Okay, so two to five mls for each vaginal examination as it kind of coated the vaginal walls. All right, so short of it is, let's just get to the results. Quote. There was no statistical significant difference comparing women who received lubricant gel during labor with those who did not in the lengths of the second stage or of the active phase of the first stage of labor. End quote. So let's just stop there for a minute. So lubing it up did not prevent labor protraction. Lubing up the vagina like a pipe didn't prevent arrest of dissent. That is why there is zero international or national guidance that says, hey, are you kind of falling off the labor curb? Why don't you just lube up that puppy up, put a lot of grease in there and that's going to do it. Vaginal lubrication is not part of any national or international labor management guideline. So the conclusion was vaginal application of lubricant during labor does not reduce the length of second stage of labor in women with singleton gestations undergoing an attempt at spontaneous vaginal delivery at term. End quote.
- [12:50]
Sponsor Announcer
This episode is brought to you by Jack Daniels. Jack Daniels and music are made for each other. They share a rhythm in the craft of making something timeless while being a part of legendary nights. From backyard jams to sold out arenas, there's a song in every toast. Please drink responsibly. Responsibility.org, jack Daniels and Old Number 7 are registered trademarks. Tennessee Whiskey, 40% alcohol by volume. Jack Daniel Distillery, Lynchburg, Tennessee.
- [13:17]
Commercial Announcer
At New Balance, we believe if you run, you're a runner, however you choose to do it. Because when you're not worried about doing things the right way, you're free to discover your way. And that's what running is all about. Run your way@newbalance.com running.
- [13:45]
Dr. Chapa
So we're gonna do this super quick. All right, I'm just giving you the gist of it. The point is three RCTs, very stringent criteria, didn't do anything. Now, that leaves 2019 intact. Now let's jump to 2022 for the second systematic review in the Journal of Obstetrics Gynecology research, which included 19 trials with an end of 5,000 patients. Actually 5,445. So a bigger study. Now, this one said, compared with standard care, which was not using lubricants at the second stage, quote, Women using lubricants at second stage had a lower incidence of perineal trauma. Great. We get that. And help prevent perineal laceration. Good. That's moderate certainty evidence. Again, we're not debating that. We get that there is data for perineal trauma protection. We get that. But they go on to say, quote, and women with the lubrication treatment had a shorter duration of second stage, end quote. So wait a minute, because we just said, remember, the first meta analysis said no. This one says yes. But look at the numbers here. The median duration, the reduction in second stage and those who had it all lubed up versus those who didn't was 13.7 minutes. That is significant. I mean, clinically, 13 minutes, especially if you're having D cells, is a long time. So I'll take it. That's good. But here's the confidence interval. And here's the problem, guys. The 95% confidence interval was minus 4. So that's good. We're on the left side of 1 on the number line. That means reduction minus 4 all the way down to the left, more of minus 22. That's a very broad confidence interval. Very wide. Now remember, in statistics, guys, confidence interval means your precision in the data, your accuracy. Another word for that is the reliability of the data. So you want to be away from one, either to the right showing an increased frequency of whatever, or to the left, a reduced incidence of whatever. But you want it to be very narrow, meaning that the scatter, you want it to be very tight, very close, meaning it's pretty reliable. A very broad confidence interval decreases reliability. This is why even the authors state, this, however, has very low certainty evidence, not low certainty evidence, very low certainty evidence. And those words mean something in statistics. That's why even in their conclusion, they say, hey, they might reduce the duration of second stage of labor. However, more well designed studies are needed to contribute high quality evidence. And in this area, end quote. So they applied the grade principle. That's you Know grade actually stands for something. It's grading of recommendation, assessment, development and evaluation. It's a way to look at the data, look at the individual data components, looking steady design, looking at the confidence interval, looking at biases and saying, is this, is this pretty accurate data or not? And even in the author's own words, they say, well, even though we found a potential benefit, the scatter is so large that it's very low certainty evidence. So yes, there is data that this can shorten the second stage, but it's not good data. And that's something that we have to keep in mind. So, guys, as always, whenever there is a he said, and in this case the he said, let's say, is the first study, which says it doesn't work, and the she said, which is a 2022 review, it says it could help. We need a referee. And the referee is major national and international published guidances, guys, not one national or international guidance says, do you have labor dystocia? Are you stuck with failure to descend, lube up that bad boy and let that baby slide on out? Even Figo. Now remember, Figo's looking at an international perspective. And you'd figure since they include even lower resource areas, do whatever you can. Lube that kid up and see if it slides out. Even Figo's good clinical practice paper on second stage management does not include lubing up the vagina, nor is it an ACOG's practice guidance update, which is clinical practice guidance number eight from January 2024 on the first and second stage of labor. If you have labor dystocia at the second stage, you've got to assess for operative vaginal delivery of some type or a C section if you are too high to assist vaginally. So I'm all for applying lubricant, I really am. I'm all for it for perineal trauma protection, but lubing it up to get the kit out, even though anecdotally it may work, when you look at that scientifically through systematic reviews and meta analysis, it just isn't there. All right, so. And I guess you know, the question is, well, could it hurt? Well, it doesn't really hurt in the sense that it's gonna cause some kind of damage. However, it may be an obstacle if you have to apply forceps or a vacuum, because you better be darn sure you wipe all that stuff off to prevent fetal injury from either the vacuum cup or misapplied or slipped forceps, blades. And you can wipe it off. We did in our case, it's just you got to ensure it's really dry. We took, you know, two blue towels, sterile towels, to wipe that all off. So it is possible. And I guess the bigger fear, at least in theory, would be that if you lube the kid so much, I mean, I guess. I guess it could be so slimy that you can drop the kid. I don't know if that's ever happened, but I'm just saying it because if I don't say it, something can happen. So I'm just saying it to protect yourself. So the idea is, well, it can't hurt. It can only help. Well, sometimes it's not that it can hurt is that it can be a hindrance to other things, like operative vaginal delivery if you have to put on a vacuum or blades. What are you doing? So the next time that someone asks you about putting lube all over the vagina to help the kid get out, you go, hey, what are you doing? Not for that. Unless you're doing it just to protect the pelvic floor. And then. I'm okay with that. Podcast family, I think we've done what we're supposed to do. As always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, let's take it home. Foreign. This has been Dr. Chapa Zobi Gyn, 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. Sam.