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Do you ever like, drive home or as soon as you get home from labor and delivery and you still hear the baby's heart tracing in your head, does that happen to you or does that only happen to me? I mean, that little gallop, right? It happens to me. I get home, I'm like oh my gosh, I gotta get this thing out of my head. Or I hear my imaginary pager or my phone go off when when I'm home and I don't even have the darn thing with me. Anyway, Fetal heart tracings are ubiquitous in labor and delivery and they're fully integrated into what we do. They're part of our everyday labor management, despite the fact that they really haven't done anything to reduce the rate of neonatal death or long term neurological sequelae. Now, there is some benefit for continuous fetal tracing, like the prevention of immediate neonatal seizures. But we know that outside of that, really all that the external or continuous fetal monitoring does is increase interventions like operative vaginal delivery or operative abdominal delivery. But nonetheless, we are stuck with continuous electronic fetal monitoring. Now there is a place where intermittent fetal monitoring can be done, according to the college, and this is in the otherwise low risk patient. They are not a toe lacquer. In other words, they don't have a previous C section and they don't have pitocin augmentation in that criteria. Low risk, not on pitocin, and they're not a toe lacquer in other words, they're not having a previous C section history. Intermittent fetal auscultation can be okay, but the vast majority of the time, just for ease of use and for reproducibility, most are comfortable with continuous external fetal monitoring, despite its limitations. Okay, so again, going back all the way to the 60s, fetal monitoring, whether external or internal, is here to stay. Since that time, we're now talking about. Oh my goodness, 60 years. Is that 60? 40. Yeah, 60 years since the 1960s when it was first introduced. Yet nonetheless, currently more than 1/4. Guys, that's 27% of primary C sections are done to, due to some non reassuring fetal heart rate tracing precision, category two or category three. And so it's important, it's vital that we all speak the same language. Now if you're thinking, wait, what the heck is this? I mean, we already, we already know the intrapartum category one, two and three designation. Absolutely. And we, we definitely do. Although some have proposed a five tier system. Hasn't really taken off. That's old. It has been for at least a decade where that was introduced to break up category two in its current form into three different categories. So you end up with five categories total. But it's kind of clunky, it's, it's kind of messy. So, so unfortunately, despite its limitations, we're stuck with category one, two and three intrapartum. Now, we're talking about this because in October of 2025, so in about two weeks, ACOG is releasing its new clinical practice guidance on intrapartum fetal heart rate monitoring, interpretation and management. Now, first of all, if you listen to our show for some time, you know that we've covered this topic a variety of times in the past from what to do with the category 2. What does category 3 mean? Why does it look that way? And none of that has changed, by the way. Category one is still good. Category three is still in general, pretty darn bad and actionable. Category two is gray, unfortunately, 70 to 80% based on who you read of intrapartum tracing, that one point or the other will be category two, which means you have to evaluate, do something, don't wait, don't delay. But it doesn't necessarily mean you have to run to section. You have to do something. And if it doesn't correct, then you may progress to C section. Of course, the worst predictor is when you watch intrapartum the, the predictable and progressive deterioration of the strip. So if it starts category one, category two doesn't resolve. You do your maneuvers, you take Away Pitocin, you give terbutaline. If it's tachystole, you give IV fluids reposition. If none of that happens in the progressive category, three, that in vivo real time deterior, that's a big flag for metabolic acidosis. Okay, so we know none of that has changed. As we have said many times before, you know, sometimes things that come out in print are new because it's a new publication. And that's our promise and our commitment on the show is let you know what's fresh and new and hot in print. This is coming out again October of 2025. But at the same time, there's nothing new. Remember, nothing is new under the sun. That's just the way they go sometimes. And we've covered that many times before on this show. What has been will be again. What has been done will be done again. There is nothing new under the sun. Is there anything of which one can say, look, this is something new. It was here already long ago. It was here before our time. There is no remembrance of men of old, and even those who are yet to come will not be remembered by those who follow. The whole idea. Thank you, Solomon, is that nothing is new under the sun. I love that. I love that because it's so absolutely true. But we still have to check this, check the data, check the science, to either verify it or refute it. And that is what is in this. Clinical practice guidance coming out in October, which is number 10, clinical practice guidance or CPG, number 10, intrapartum fetal heart rate monitoring, interpretation and management. Very quickly, I'm just going to tell you the three main points, guys, three. That's it. Three main points here as a reminder, because we've covered this already in the show, but three points here of things that are vital for us to remember. The first has to do with what we've already mentioned. Is there a place for intermittent fetal monitoring? And the short answer is I've already spilled the beans there because it's yes. Otherwise low risk, not being stimulated with oxytocin and not having a previous history of C section. So. So that's the end of that. Even though there have been some gaps there in terms of how frequent you should check, there's some guidance, but that there's no real set de facto protocol. Everyone does it differently. So is there a place for intermittent fetal heart rate tracing interpretation or Doppler assessment? Yes, and we're going to cover that briefly. Second, has to do with maternal oxygenation as a way to rescue category 2 tracings. Now I know if you're part of our podcast community, you, you've heard me talk about this. Cuz the short answer is stop doing that. Unless mom is hypoxic or uptunded, which goes with the cause of her hypoxia. Giving mom additional supplemental oxygen to quote unquote, fix a Category 2 strip, not only is it not evidence based, potentially, according to some limited studies, could be harmful, especially in the extreme preterm child, because that could trigger free radical formation. Fetal hemoglobin is such an avid binder of low partial pressures of O2 that you don't need to give supplemental oxygen. We're going to briefly touch on that, even though it seems that we're touching on it right now. And the number three is has to do with AI. That's right, artificial intelligence, because that is a big deal. Artificial intelligence is definitely in medicine and I've covered this in the past in terms of mammography. It does great to listen for to pick up some small visual cues that that a physician Ms. On first inspection. So AI for mammography or even for brain scans. Phenomenal. There's definitely a benefit for that. The question is, even though there's some companies already having packages of AI for fetal heart rate tracings, what does ACOG say? What is the official stance as of October 2025 regarding AI technology for interpretation of these strips? We're going to talk about that. So those are the three things we're going to do. Okay. We're going to talk about the use of intermittent fetal monitoring when applicable. We're going to talk about maternal O2 and how it really does have some limitations. We've got to be careful with that. And then we're going to talk about AI and fetal heart rate tracing potentially at some point, guys, we're going to get there. I have no doubt that we are going to do AI as an adjuvant, especially on the Category 2 tracings. And there's plenty of published data for that. Plenty. But as of right now, we're just not there. We're not there because there's a lot of questions that remain. So I think I've set it up enough. That's what we're going to talk about. We're going to review ACOG's new Clinical Practice Guidance Number 10 coming out in October 2025. We'll be right back. Tired of all the spin in women's health education? Yeah, so are we. This is Dr. Chapa's OBGYN no Spin podcast. Eczema isn't always obvious, but it's real. And so is the relief from EBGLIS. After an initial dosing phase, about 4 in 10 people taking EVGLIS achieved itch relief and clear or almost clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing.
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EBGLIS Lebricizumab LBKZ a 250mg 2ml injection, is a prescription medicine used to treat adults and children 12 years of age and older who weigh at least 88 pounds or 40 kilograms with moderate to severe eczema, also called atopic dermatitis, that is not well controlled with prescription therapies used on the skin or topicals, or who cannot use topical therapies. EBGLIS can be used with or without topical corticosteroids. Don't use if you're allergic to Epglis. Allergic reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with Epglis. Before starting Epglis, tell your doctor if you have a parasitic infection searching for real relief?
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Ask your doctor about ebglis and visit epglis.lilly.com or call 1-800-lilyrx or 1-800-545-5979. As a quick disclosure, I am once again on the move. This is Friday, September 19th. When I'm recording this, I'm actually at the hospital, hence why I'm sure there's some kind of reverberation or echo because I'm in one of the call rooms. But nonetheless, I'm hoping that our producer can do something with that. Can I just give a quick shout out to our team? We had three fetal slash baby saves. Can I just say three saves. And we just finished one this morning. Patient came in, a little teenager with acute chest pain. Blood pressure was 200 over 110. Yeah, y'. All, did y' all get that? 200 over 110 we put on the monitor. By the way, she's 29 weeks on the monitor. Classic category three. Classic category three. I mean, flat with seagull appearance to the lates now in 20 minutes, guys. 20 minutes to arrive to go. Quick, quick history, no vaginal bleeding. We got her on mag, lowered her blood pressure. I took a look at that strip and like, look, we don't have time for mag. We're not going to mess with that. We're not going to Mess with steroids. This kid is in danger by from admission and triage to to assessment with CRNA at bedside and neonatology at bedside to the OR was 20 minutes. We rescued that child by. By section and we're able to do a low transverse C section and the baby got resuscitated. Thankfully, he's doing well. But in 20 minutes that gas guys had a pH of 6.9 and a base excess of minus 20. Base excess of minus 20. Acute metabolic acidemia. Now, baby is fine. And I told her because, you know, she had a spinal. She was awake, her mother was in the room. It was a controlled stat. Told her that 20 minutes more @ the house. This child could have died. That was a save. We rescued a child in acute acidemia with 20 minutes from entrance to delivery. Amazing. I mean, I'm telling you, that's a win for the team. Our team needs to be proud of that. And everybody shares this with them. I'm very proud of that. Quick response number two is we had a patient just two days ago. Classic abruption. Classic abruption. And again, another teenager, prima gravita, port wine, amniotic fluid with spontaneous rupture. She came into triage. By the time we diagnosed an abruption which was 15 minutes later. We had her delivered within 25 minutes. That was a save. That apgar at one minute was one. That's one. Eight minute apgar was. I'm, I'm sorry, eight minute apgar, five minute apgar and thereafter was eight. Because they kept it just to make sure. That's a save. Y' all get that? And I told the exact same thing. I'm like, we just had this conversation a couple of days ago with another patient. 30 minutes more @ home. That child very likely would have demod. That's a save. And then the third was that we. We intervened with this patient who was just about to start an induction. I'm like, baby looks pretty big. We did an ultrasound at bedside. 4.5 kilos with diabetes. So we had the discussion about shoulder dystocia and the cut off based on national guidance. She said, I'm out. I don't want to risk it. I said, well, thank the Lord because I don't want to risk it either. Went back for a section for her nine pound, nine ounce baby. That was a save. That was a. That we prevented the shoulder eminent shoulder dystocia. And so we got out. Those are three fantastic saves, guys. One week, in addition to all the regular calls and routine things that we had. So our team Works hard. We have such an acute level of pathology here. And as I told them just a little while ago before I left to come do this, this recording, because things have now, you know, calmed down, is you all need to be proud. Those three babies, we were literally knocking on death's door. Thankfully, that door remained closed. And as I told the residents, not today, Satan. Not today. Those are three saves. So very proud of our team. Kudos to them for acting fast, but very fitting because it was a classic, I mean, textbook category three strip just this morning for that 29 weeker with severe preeclampsia and her chest pain and, you know, not being anything acute, it's just the pressure was too high and I think a little bit of anxiety also contributed to that. But no evidence of MI or cardiomyopathy. Classic category three. So knowing the strips, knowing the categories is vital here. Vital. So let's start this quick review of clinical practice guidance number 10 coming out, oddly enough, in month 10, that's October of 2025, with a quick word on intermittent auscultation. Because I get asked this frequently, either by consults or med students, you know, can we do this? Absolutely. There's no question you can do intermittent auscultation in the right context. And let me read this little excerpt from this. We're going to do this quickly because again, there's nothing really new here except for the AI part and the, and the validation that oxygen as a rescue option for Class 2 Category 2 tracings is not necessary in the absence of an obtundant patient or true maternal hypoxia. So very quickly, let me read you this about intermittent auscultation. Quote, intermittent auscultation may be used during labor for patients at low risk of fetal acidemia who are not receiving oxytocin. End quote. So let's stop there for a minute. So if you're thinking, well, wait a minute, what does it say about TOLAC in there? There's nothing about TOLAC in there that's absolutely true. For that statement, you need to go to a separate ACOG guidance, which is ACOG practice bulletin 205 from February 2019. That is vaginal birth after C section. In that 2019 guidance, which was reaffirmed just last year, guys, in 2024, the statement is there. See, that's why you can't just look at one guidance, because this is not under that. The current discussion from October 2012 on intermittent auscultation, you gotta go back to the one that was reaffirmed last year in 2024. So here's what it says about TOLAC and about monitoring. Quote Once labor has begun, a patient attempting TOLAC should be evaluated by an obstetrician or other obstetrical care provider. Most authorities recommend continuous electronic fetal monitoring. There are no data to suggest that intrauterine pressure catheters, however, or fetal scalp electrodes are superior to external forms of continu monitoring. In addition, there is evidence that the use of intrauterine pressure catheters does not help in the diagnosis of uterine rupture. End quote in other words, while it's all consensus opinion, if you're doing a tolac, use some form of continuous fetal monitoring, whether internal or external. In other words, you do an internal if you really need to figure out montevideo units. But but intra monitors really don't help that much in the prediction of rupture. What helps is knowing a continuous monitoring tracing to see if there's bradycardia because an acute change in the fetal heart rate like bradycardia or recurrent D cells could signal rupture. All right, so the most common sign of of uterine rupture isn't a loss of pressure, although it very well could. You could see that the most common finding of uterine rupture on a continuous fetal monitor is an is an alteration is an abnormal the fetal heart rate tracing. Okay, so in this guidance from the college from 2019 on vaginal birth after C section, that's where it's very clear. Let me read it to you directly, just one sentence. Quote Continuous fetal heart rate monitoring during TOLAC is recommended. End quote why? Even though whether internal is no better than external, we do want to catch quick changes to the fetal heart rate which intermittent auscultation can miss. Okay, so even though the issue on TOLAC isn't mentioned in this new October guidance on intermittent, it just says for those who are low risk and TOLAC automatically is not low risk. So I guess it's embedded in there. You got to read between the lines. And those not receiving oxytocin, please remember that if you're getting PIT for augmentation or induction, you need continuous monitoring and if you are toe lacking that needs continuous monitoring, otherwise intermittent monitoring for the otherwise low risk patient. And spontaneous labor can be okay, although we're not really sure what the time to check the fetal heart rate during the contraction or immediately after how frequent we should do that. But there is some minimal guidance here. Quote There is minimal evidence to guide the optimal Frequency of such auscultation, the American College of Nurse Midwives and the association of Women's Health, Obstetric and neonatal Nurses. That's aowon recommend an intermittent auscultation interval ranging anywhere between 15 to 30 minutes during the active phase of the first stage of labor and and then increasing that frequency to every five to 15 minutes during the second stage of labor, as long as the auscultated fetal heart rate and labor characteristics are normal. So just to be clear, this new guidance is not saying that continuous must be done 100% every single time. No, there is a place for intermittent auscultation. It just really has to be done in a low risk patient. And most providers are comfortable with continuous. But. But continuous, as we mentioned in the intro, while they do have a reduction in immediate neonatal seizures, quote there is no evidence that continuous fetal monitoring causes a reduction in perinatal death or cerebral palsy. However, continuous fetal monitoring is associated with an increased risk of cesarean delivery and operative vaginal birth. End quote. That is right out of the October 2025 guidance. Okay, so one of the first things of the first of three things we're talking about is is there a place for intermittent auscultation? Of course, absolutely. No question. But it's got to be very selective. Even though continuous monitoring has issues, it allows for easier interpretation, it allows for a better record. But if the patient is absolutely low risk and not getting Pitocin and not undergoing tolac, then intermittent auscultation can be performed with those time guidances, as we discussed, every 15 to 30 minutes during the active phase of the first stage of labor and then every 5 to 15 minutes during the second stage. And the way that you do that with the handheld Doppler is listen during the contraction and for the first 30 seconds to up to a minute after the contraction. Okay, so it's during and then in the immediate at least 30 seconds after the contraction. And ideally that should be recorded so you have a written record. Okay, so in this clinical practice guidance number 10 from the college, it states that the affirmation that intermittent fetal heart rate tracing can be done in some select patients. All right, that's the end of that one. Very quickly, let's get into the rescue approach that many hospitals do, many labor and delivery units do, which is applying supplemental O2 to the mother as a way to correct a category two strip. So let me read this very quickly. Quote. ACOG recommends against that means don't do it against routine maternal oxygen administration for category 2 or 3, fetal heart rate tracing in the absence of maternal hypoxia. End quote. Guys, we're not going to get into this because I've covered this many times before. Go back to the archive. It potentially, the idea of, well, it can't hurt and it could possibly help is wrong on both counts. It doesn't help unless mom is has hypoxia, and it potentially may hurt, especially at earlier egas, as the XX oxygen in utero can trigger free radical formation, which is an enemy of the germinal matrix. Okay? So even though historically that is done. Don't do that. The way you correct a category 2 or 3 strip is reduce contraction frequency if they're tachy. Systolic is give IV fluids to increase placental blood flow, stop any offending medications, and reposition so that potentially the child can get better blood flow based on maternal decompression of the atrial caval system. That's how you do it. But there has been no difference in PH scores, no difference in APGAR scores, and no difference in neonatal intensive care admissions just because mom got supplemental O2 excluding cases of maternal hypoxia. Okay, so that's rule number two. And again, we're not going to belabor that because we've talked about that many, many times before. And I'm going to thankful that that is in here. It's also under the ACOG guidance on ways to minimize interventions in labor and delivery. Okay. All right, so We've covered number one, we've covered number two. We have covering. We have to cover number three, which is AI's role or its potential role in fetal heart rate interpretation. And we're going to do that when we come back. Oh, thank you, Michael, for a little AI artificial intelligence. What is this? Our interlude? Right. I guess a little Terminator sound. Is that what that is? The theme song from the Terminator. Great. So cheesy. We'll be right back. And now a word from our sponsor podcast family. I am extremely thankful and grateful to have this new personal corporate sponsor partnering with our show. Right. It's unique to the Choppa Podcast community. I want to introduce you to a product that I use and I love. I use this every day. It is called the Strong Coffee Company. Strong Coffee Company. Now, not strong as in the amount of caffeine, but strong in what is in it. Strong actually stands for striving to reach our natural greatness. This is not your average cup of coffee. You can get that anywhere. This is coffee plus collagen, coffee plus protein, coffee Plus L Theanine and adaptogens. There's a variety of different products that they offer including instant, ready to use mix and whole bean options. I specifically like the collagen variety. I think it tastes great. I think it's good for our body. And there is published evidence that these adaptogens, caffeine and L Theanine boost overall performance without the caffeine crash. This was out of July of 2024 out of APTA Scientific Nutritional Health that reviewed this kind of components in one drink mix to boost overall awareness Boost overall performance without that caffeine crash. This is unique to our podcast community. Again, strong coffee company, but you have to use the link that is meant for the Choppa podcast community. That link is in our show notes. Again, I want to introduce you to the strong coffee company striving to our natural greatness, which is your cup of coffee. Plus it's coffee 2.0. I think you're going to love it. I use it every day and I hope you find it helpful for you as well. Use the link in our show notes for your 20% discount so you get 20% off just because you're part of our podcast community. That is through the link only in our show notes. Again, the strong coffee company with the link in our show notes for 20% off whatever you order online. When did making plans get this complicated? It's time to streamline with WhatsApp, the secure messaging app that brings the whole group together. Use polls to settle dinner plans, send event invites and pin messages so no one forgets mom 60th and never miss a meme or milestone. All protected with end to end encryption. It's time for WhatsApp message privately with everyone. Learn more@WhatsApp.com well, I know that with the editing it looks like I'm just sitting down at one recording. I actually not. I gotta. I got called for triage, remember? I'm at the hospital right now. So again, apology if the echo's there or the audio's a little off, whatever. But I got called for a possible S ROM and the residents are checking her out. Everything's good, everything's good and everyone's taken care of. So. So now that I'm back and I've reconnected with our with our producer, he's like, are you gonna leave me hanging here? Hold on man, I'm coming back. So thank you Michael for waiting. So very quickly now, a quick thing on AI. Okay, AI is the bomb. AI is phenomenal. I am a big fan of it. I also know that it's got some limitations, although in the future when the kinks get worked out, it's gonna be great. It's already being used as a ancillary agent for reading some MRI brain scans and of course for mammography. We know that the value is there, but how does it fit in for fetal heart rate tracing is, yeah, shows promise. But as of right now, the official stance, or at least it will be the official stance in two weeks when this comes out in October, is that use this as an, as an educational thing, maybe a little academic experiment, but not really to guide management. Quote the ACOG recommends against primary reliance on computerized approaches for the interpretation and management of the fetal heart rate in labor. According to this discussion, quote There have been studies examining the use of artificial intelligence or AI to create approaches to interpreting the fetal heart rate and to better predict fetal acidemia. In a systematic review and meta analysis of data from more than 55,000 patients. Use of AI in the interpretation of intrapartum FHR fetal heart rate did not change the incidence of neonatal acidosis. Thus again guys, let me just tell you, these are not my words. I'm reading directly from the new guidance coming out in October. Thus these approaches are still inadequate to independently guide clinical care. All to say maybe use this as a, as an ancillary, just maybe get a little opinion of it, but it should not be relied on as the primary interpretive tool. So as they say right before the conclusion on this topic, quote at this time there are no clinical trials that support the notion that computer based fetal heart rate interpretation improves neonatal outcome. Nor are there case control or cohort studies that have AI approaches that appear to improve the prediction of fetal heart rate monitoring for fetal hypoxia or acidemia. End quote. So that is a big womp. Womp, meaning it's on the horizon potentially it might could do something, but we're not quite there yet. On to say if you've got a vendor as somebody has approached me, hey, we've got a new package deal on AI for your fetal heart rate tracing. My answer was thank you brother. That's really not thank you for seeking me out, but I've got eyeballs and I've got 25 years of experience and I've got a specialty training. I know how to. I think I'm okay right now. Plus there is no professional organization that has endorsed you yet. You come in with an endorsement that I can print, then we'll talk. And they very quickly kind of looked at Me sideways and then went on their way. Hey man, I'm just trying to be true to the data so it potentially there is something there. But as right now, according to the college as of October of 2025, we're not there as using AI as a primary evaluation tool. Now, something else that's also been looked at, and I'm not going to get into this quickly, is the use of stan. All right, we try to look into the data. This is about three years ago. There's not enough there. STAN stand for ST segment analysis as part of the fetal heart rate tracing. Again, I'm not going to get into it because even that ACOG says don't use it. We rec. We recommend against its use because it's just not reproducible and doesn't really change any outcome. There is something called the ST segment or STAN ST segment analysis that could potentially look for defects in fetal oxygenation. And the data looked so hopeful. But unfortunately, as of right now, because of all the limitations and lack of true benefit in the neonatal outcome, use of stan ST segment analysis and interpretation is also not standard. So what have we covered here? We've covered ACOG's new Clinical Practice Guidance Number 10 coming out in October 2025, saying there is a place it's okay for intermittent auscultation. The patient knows that there is some limitations, just as there's limitations with continuous monitoring. But in the appropriately selected low risk patient, which means not on Pitocin and not a TOLAC sit, it may be fine. The second is the use of oxygen as a as a tool to correct category two or three tracing. No place it does not belong in there. But what does belong in there is alteration of contraction pattern, maternal position changes and IV fluids to try to maximize utoplacental blood flow. And the number three is the use of ancillary artificial intelligence, which absolutely is coming. It's coming, but it's not there as of yet. Podcast family, I'm at the hospital and I just got a text on our secure tiger text that they need me back in labor and delivery. So real quick, Michael, thank you for jumping on this. I know it's your afternoon off, but you demand. And to our podcast family, thank you for being part of our podcast community. As always, we're here to let you know with hot in press or soon to be in press, and we've just covered something coming out in two weeks. We'll see you all on the next episode of the no Spin OBGYN podcast. Podcast Family. We're thankful for all of the support that you've given us throughout the years. This has been the OBGYN no Spin podcast. We'll see you on the next episode.