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This is a job for Indeed Sponsored Jobs. Podcast Family. When I say I love the comments, the questions that come into the show, I absolutely mean it. You know I do because there's such great ideas and content for this show. So thank you for that. You all see it as a question, I see it as show material. Plus, we've got recent data as of March of 2026 to back up what we're going to get into today. All right, so it's not just a question that came in, which it is, I'll tell you that in a minute, but it is also related to recent content from this year, 2026. Now let me set this up. So there's a graduating OB GYN resident somewhere in the country and she's already looking into her onboarding at her next, well, at her first real job as new faculty at another place. All right, so as she's getting ready to graduate, a lot of life changes going on, she's moving to another location. She sends me a message. Hey Dr. Chaba, I have a quick question. I'm just looking at some of the materials, some of the onboarding stuff that my new hospital has, and in terms of their vacuum assisted devices, when we're doing a vaginal vacuum, they have something called the 20 minute rule. Now they also have a pop off rule, which is three pop offs, but they have this 20 minute rule which is, well, what is that about? So I messaged her back and said, wait, does your current hospital have a 20 minute rule or what is your policy for vacuum? She said, no, it's no more than five polls. All right? Every hospital is different and no more than three pop offs. Okay. That's also kind of standard. She says, but we don't have a 20 minute rule. We don't have any time on it. And I said, oh, that's very interesting because the 20 minute rule is actually a thing. Not only is it a thing out of the manufacturer for the mighty vacuum, the single handheld vacuum. We'll get into that in a minute. But it also is part of some guidance and there's a lot of data that goes back to the 1960s about the 20 minute rule. So here's what we're gonna get into. Whether your hospital has just a straight number of pull or pop off protocol for vacuum, even if they don't have a quote unquote time for it, meaning like a time from application to delivery, the maximum time that that should be. Even if they don't have, that doesn't mean you don't need to be aware of this because it is absolutely linked to patient safety. So let me be very clear. There's a lot of variance here in how people do vacuum. And I'm going to prove that to you by some data here in a minute. Some use just straight number of polls, some use a number of pop offs, some use a combination. Some use that combination and a total time from first application to delivery, which is actually the safest way to do it. All three are all right. Even though we don't actually know the number of polls that's considered safe. There is some data that more polls is obviously more harmful. Same with pop offs. We'll get into that in a minute. But there is something called the 20 minute rule and it's for patient safety. So you've got to know this whether your policy has it or not. So that if you first apply, you need to tell your nursing staff and everybody in that room, we've got to be done here from first application to delivery, if you in 20 minutes maximum. So don't say I never warned you. Warned you. Didn't I warn you? Yep. This is important. You've got to know this for patient safety. This is a thing. The 20 minute rule isn't made up. It's a thing. Although some hospitals use it and others don't. I think I've set it up enough. We will be right back. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast. Yes, it's true. There is a lot of variance in protocols across hospitals. So the first thing I told this, soon to be a graduate Resident, I said, hey, check with your policy and procedures because you may have a 20 minute rule, you just don't know about it. As we all typically focus on traction polls and our pop offs. You may have one and just not aware. But there are some non negotiables that when using a vacuum, but most if not all labor and delivery units have, they all have a pop off limit. Although some vary by two, some say three, they all have the lack of progress rule, meaning if each pole doesn't have some kind of measurable descent down the birth canal, you really got to assess. Some have a number of traction attempts, most list that or limit that to no more than five. Usually it's about three with a reassessment after the third. And five is a hard cutoff. And surely somewhere embedded in there there's a cumulative time of application. Now cumulative means time from first application to delivery. Now some use that rule, others use total vacuum time, meaning time the vacuum is on and then whether you leave it on or you take it off, in between contractions, whatever, because there's no data that one is better than the other. But some limit that to more than 5 minutes Total application time. So you're not sucking on the baby's head continuously. All right, so whether there's a pop off limit, which usually they do, whether it's a traction pull limit, which usually they do, or a time limit, which is either total time that's 20 minute. And I don't mean total time that the vacuum is on, because 20 minutes, a long time to have a vacuum, nobody would ever do that. But from time of first application until delivery, that's called trackable time. And that trackable time in most, if not all year units, even internationally, is 20 minutes. I'm gonna tell you where that history come from. It's not random. The 20 minute rule is rooted in history. And it's even in the instructions for use in the mighty vac, right? They're like, hey, 20 minutes from first application. If that kid's not out, you gotta assess what's going on. And that's really to protect the patient, meaning both the child and the mother. So that you do a vacuum and then three hours later she's still undelivered. That's not a thing. There is a time from first application to when the child should be delivered, which is a good reminder, guys. It's a good reminder that you don't put on the vacuum willy nilly. You put on the vacuum when you think that joker's gonna work. All right? Because most successful deliveries with a vacuum. Here it is, guys. Based on the data, four minutes. Four minutes from first application to that kit is out. It's not like it's gonna take an hour. And you know, I've been asked to review some things where a physician puts on a vacuum. There's no descent, like, oh, okay, well, never mind, never mind, we're gonna stop that. And then they keep with the second stage for like another two hours. That's not a thing. Just be clear. That is not a thing. Once you put on a vacuum, you are on the clock either for total vacuum time, meaning the vacuum is applied, which should be no more than about five minutes, versus total trackable time, which is from first application to the child's delivery, that should be no more than 20 minutes. So whether your hospital has that actually listed out or not, you gotta be aware of that for patient safety. I warned you. Didn't I warn you? So never say I never warned you. Okay? It is a thing. And I find this fascinating because I bet you that this graduating resident, they actually do have a 20 minute rule or some kind of time assessment, not just pop offs a number of polls because that's good patient protection. But that actually would be kind of incomplete. There's more to it than that in terms of patient safety. Okay, so this is important. This 20 minute rule is a fascinating topic. I got to ask this question. I'm like, that is really, really good. And there's a lot to go over. We've got to cover that on the show. Remember, vacuums are phenomenal. They are truly C section saving when used appropriately. And of course, just quickly to review, ACOG has a practice bulletin, of course, and I'll list that reference in our show notes. But there's outlet, which is your highest chance for success because that's where the bab gestation is plus five. So the baby's crowning, mom's exhausted and or there's a big D cell. You just need to get the kid out. I totally understand that that is your best chance of success because there's very little rotation necessary and the baby's head is right there. Remember, there is data that the fetal head position to perineal distance, if you got to transverse a longer distance, that is linked to higher rate of failure. Now, it doesn't mean it's going to fail, but this is just statistically. Okay, so the outlet should have your best chance of success. Also has your lowest indication. You could just say maternal exhaustion, and that's legit because you gotta get the kit out. Then there's low vacuum at. Now, I don't mean low vacuum in terms of pressure, I mean low in terms of station. That's two plus to four plus. And then there is mid vacuum, which traditionally the term, you know, mid application was meant for forceps, but you can still do it from zero to plus two. That, that is very reasonable. When there's an indication and you are aware of the baby's head orientation and you've got skill to do that. But in general, if you've got bad D cells or the baby hasn't descended from zero station, you should really be considering something else. But in select circumstances, ACOG recognizes that mid position. Now, I don't mean mid position again in terms of orientation, I mean mid in terms of station zero to plus two. There is a role for that. If you got to get the kid out and you think that's faster than a C section, then knock yourself out if you've got that skill. But it's either outlet, it's either low from 2 plus to 4 plus or it's mid. Okay, so we all get that, that's a standard. But I just wanted to review that in terms of what we're talking about here, that does influence success. And whether you're doing a three pole limit, whether you're doing a three pop off limit, you've got to understand this limit for time. So let's get into this history and then I'm going to tell you the data, including 20, 26 data that says, yeah, if you apply that vacuum and the kit comes out three hours later, there's going to be a problem. So there is a time limit from first application to delivery. But check out this history. Ah, but before our history, a quick word about our sponsor, tona Activewear. Remember, 16% off with the link in our show notes. And if you're driving can't look at the show notes, it is tonaactive.com discount choppa no spin OBG, that is tonaactive.com discount chopanospin OBG for 16 off. Anything on the Tona Activewear website. Now back to the history. Now, although forceps had been around for a long time, with the Chamberlain forceps, that's what's basically robbed. Well, sorry, how about borrowed the practice of obstetrics from midwifery, because, remember, the modern field of obstetrics was birthed, no pun intended, from midwifery. And I've got an episode on that. Lessons learned from midwifery. You can go back and listen to that in the archive. But it was really the development of forceps that helped with obstructed labor that also put the patient from a sitting or a throne position or princess position, down on her back as a lithotomy position. So that the typically male provider could now put the hands, the little spoons, meaning forceps, into the vagina to assist with delivery. So forceps were first, and then the vacuum came about. Like, hey, this is kind of easier. Let's do this. The problem is, in the 1950s and 60s, when there was the original kind of rigid cup Maltrom vacuum, there was no real rules here. And things were kind of loosey goosey. I'm going to give you some history. That is whack. Whack, okay? And this was real. This is why there's rules and people and why the vacuum has still sometimes gets a bad rap. But this was. We're talking about 70 years ago. 70 years ago, because nobody knew, hey, what the heck? I can just put a vacuum on this kid and get the kid right out of the vagina. Even at first stage? Yeah, you heard me. Even at first stage. That was a thing like, oh, six centimeters. Not coming down, baby. You think it's not coming down. I got a vacuum. So this was the thing. The Maelstrom vacuum did some whack a mole things back in the day. I mean, we're talking about in the UK, Australia, even some in the US where traction had been maintained for up to 60 minutes. Traction to prevent the kid from going back up into the pelvis. Yeah, that's smart. Terrible outcomes, needless to say. So then in the 1960s, people kept reporting these things like, hey, we need to have some safeguards here, because again, it is wild, wild west up in here. What people are doing. There's severe scalp lacks, there's intracranial hemorrhage, of course, there is subgalial bleeds. And there was this demand for. For rules. Then came 1967. There was a researcher which was wilder W I D E R. Not wilder, wider. Sorry. W I D E R. That really did this review saying, look, man, we cannot do this in the first stage. This has to be limited to the second stage. And here it is. There has to be, based on the data, maximum application threshold of 15, no more than 20 minutes. Oh, hold on a minute, y'. All. 1967. And if you're asking was I around. No. How old do you think I am? No, no, of course I wasn't around. I was maybe a thought in somebody's gametes, but I wasn't around. So this, this was, this is where the 15 to 20 minute rule first started kind of popping up like, yeah, man, there's data here that that kid really should be. There was another publication that came out by the late 80s, that was grease et al, G R E I S that said, yeah, this seems to be the way to go. Especially if we modify that maelstrom from this kind of hard metal cup to something that's a little bit more skin favorable. Then that's where we get the more modern looking cups, whether it's a bell or mushroom, to get away from the rigid metal. Okay, and, and here it is. That 15 to 20 minute rule was steeped in the history of bad practice and in the data that said, man, you know what? Things start to go south from a duration of first application to past 20 minutes, there seems to be a higher risk of harm. And that's what the current literature says. Most successful vacuum assisted deliveries are done within four minutes of application. So when you're doing a vacuum, especially for the newbies about to leave, because we're doing this in mid June, about to graduate and be brand new attendings, Lord help us all, or brand new private practice providers, when you're doing a vacuum. Open communication, Open communication. Hey, I've got the vacuum on the baby's head, but no vacuum is applied. Do not start the clock the first time that you pump that handle or somebody's pumping up for you. If it's a two personer and it goes up to the green zone, you go, vacuum is now on that clock should start. And to say guys, in 15, no more than 20, this kid should be born. You. I'm on the clock here. Since most are delivered within four minutes of application. So don't do a vacuum unless you're sure that number one, it's going to work. Number two, you obviously know the baby's orientation. And then number three, you think you can do that in a timely manner. Also, most deliveries are done even though this was typically done with forceps. This extrapolated to vacuum within three tractions or three poles. Okay? So everything has its historical basis. Even difficult mid pelvic forceps. Those were typically delivered within three polls. Okay? That's where the three came in. Even though. Here it is guys, here it is. ACOG's current stance from practicables in 219 says it's good to have these time limits, it's good to have these safeguards. That's great. However, however, we don't really know what the safest number of polls, the safest number of pop offs is. Except that things get worse the higher that those numbers go. Okay? So they don't want to give you a straight number because it leaves room for some, you know, some practice discernment. But just know that the data behind that is still present. So here's one thing they do state that the number of cephalohematomas, okay, cephalohematomas was 28% in newborns when the application to delivery exceeded five minutes. Now, exceeded five minutes is a lot for interpretation. Was it six? Was it 10? Was it all the way to 20? What does that mean? But that's again where you get the five minute reassessment. Remember, most are delivered within four. And they say, yeah, this is in the ACOG practicals. And there was a study that found cephal hematomas went up the longer in duration that that kid is not born. And in this reference, they're using five minutes. Okay? So even though there is not a distinct a set number of cutoffs where absolute fetal harm will happen, the more that you use it, the more time that elapses, the more pop offs that happen, risk starts to increase. Everybody agrees with that. Okay. All right, we're almost going to be done here. I want to tell you this. Recent data from 2026 out of March out of the European Journal of Obstetrics and Gynecological Research and Reproductive Biology. That's a long title. European Journal of Obstetrics and Gynecology and Reproductive Biology. This was March of 2026. And I'm also going to tell you the manufacturer input, especially for the, for the Kiwi Omni cup and the Mighty Vac, because they do have a time limit specified. Just so you know, they do have a time limit if you're using the Mighty Vac or the Kiwi. Okay, so good, so good, so good. New markdowns up to 70% off are at Nordstrom rack stores. Now stock up and save big on shoes, tops, dresses, accessories and more must haves for summer. Join the nordiclub to unlock exclusive discounts. Shop new arrivals first and more. Plus, buy online and pick up at your favorite rack store for free. Great brands, great prices. That's why you rack. But first, before we do that, and then we're going to wrap this up. March of 2026 out of this European journal they followed. It's retrospective though, so you know, it's got some limitations. But still, retrospective date is good. We've got something in IRB right now. For our institution doing a retrospective study, some things you just got to look back on because it's too hard to track going forward. Okay, so a large retrospective study of 2,355 vacuum assisted deliveries. So 2355. And what they found was, look, if this thing ain't out in a short amount of time, it's probably not going to come out. The Success declined from 98%. 98% at the first few minutes after commencements. 98%, guys, think about that. To about 61% at 20 minutes. So you drop a lot. You almost drop 40 percentage points. All right, so 98% at commencement, like, okay, I'm good. I'm going to do first traction. Highest chance of success in the immediate short term. And then by 20 minutes, that success dropped down to 61%. Now, at the same time, composite neonatal morbidity rose from. Here it is, listen to this, guys. 12% to 57%. Actually 57.7. So we'll say 58% over that same interval. Y' all get this, guys, guys, this was March of 2026. So when this soon to be resident grad messaged me, I'm like, oh my gosh, there's data on this? Yeah. The longer that you go in times of, in terms of duration, absolute minutes from application to delivery, the worse it's going to be. So, yes, there is something called a 20 minute rule. Not just number of tractions, not just number of pop offs. Okay. The manufacturer also notes this. It's in their instructions for use or IFUs for kiwi and mightyvac, that the total application time, and that is defined as cup first applied to fetal scalp delivery. 20 minutes. That's the entire procedure, not just the cumulative sections, that the traction is actually applied. All right, so it's in the instructions for use from the manufacturer and in most of the data when they talk about total traction time or total vacuum time, it's from first application to kit out and then you have a sub time of that which is actual vacuum use. I say both. I say, hey guys, vacuum is on. Now it's off. Because I take vacuum off in between tractions. That's just my preference. I know the data is not that clear on that, but I don't like to have suction on all the time, so. Or I move it all the way down to the very low part of green. Okay, Just keep it on like in the yellow part and that's fine. But I don't want full vacuum on all the time. So say vacuum is Back up. We're back up to green. And now count how long are we in attraction? Pull. Remember, most pulls are a count of about 10 seconds for a contraction. And maybe you do two in a row, so that's 20 seconds. Think about it, guys. Four or five minutes of actual vacuum on is a long time. So this is why it's not talking about total vacuum time. It's talking about first application to kid delivery. Last thing, guys, I'm going to wrap this up. This whole issue of different criteria and hospitals having different things is very well known. There is actually a published review of four national guidelines. This was the Royal College of Ob GYN Australia and New Zealand College of Obstetrics Gynecology, ransog. They took a look at the Society of Obstetrics and Gynecology Canada and acog. Right. So this was a recent review, looked at four national guidelines, rcog, ransog, SOGC and acog, and found, well, these are all different. They all say something slightly different in their guidance. ACOG says we don't really know a true number. Just it gets worse the longer that you go. Others do have a time limit, others don't. There's a lot of variance here from national guidelines, even in terms of national of detachments, cup pop offs. And the only one that really says, hey, there should be a 20 minute total rule was a Japanese obstetric guideline that says in addition to all that stuff, there should be a 20 minute total application time. So once again, guys, it's just so you can say, don't say, I never warned you. Not only are number of polls important, not only are number of pop offs important, not only is total applied vacuum time important, but total vacuum application is important. It means from first use to delivery, that is called the 20 minute rule. All because of some whack whack stuff with the Maelstrom Historically podcast family. As always, we're thankful for you. Oh, before I go, Michael, hold on to that graduating resident. You did it. Good for you. I wish you the best in your private practice attending role. Keep in touch. Thank you for being part of our podcast community for this wonderful question. You went into an episode. There you go. The 20 minute rule for vaginal assisted vaginal delivery and 2026 data. Michael, now that we've done all that, come on now, let's take it home. This is Dr. Chapa's ob gyn no spin podcast, Sam.