← Dr. Chapa’s OBGYN Clinical Pearls 
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- [00:02]
Doug
And Doug, here we have the Limu emu in its natural habitat, helping people customize their car insurance and save hundreds with Liberty Mutual. Fascinating. It's accompanied by his natural ally, Doug.
- [00:18]
Dr. Chapa Zobichyn
Limu is that guy with the binoculars watching us.
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Doug
Cut the camera. They see us.
- [00:22]
Dr. Chapa Zobichyn
Only pay for what you need@libertymutual.com Liberty, Liberty, Liberty, Liberty Savings vary unwritten by Liberty Mutual Insurance Company and affiliates Excludes Massachusetts. Misoprostol, otherwise known as Cytotec, is an E1 prostaglandin that's used primarily in obstetrics intrapartum for either cervical ripening, like when the Bishop score is under six, or as a way to induce labor. In other words, to get the process started. Now, once labor has started, if the patient stalls, then the medication of choice is typically IV oxytocin. Pitocin. We get that. That's a thing. However, it happened to us recently when I was in labor and delivery where we had a patient who stalled after 6 centimeters. So she's in the active phase. Contractions kind of went kaput. She's not a prior section, and so she's just kind of hanging out there, despite the fact that we already did artificial rupture of membranes and arom. And so we said, you know, hey, you're kind of stalling her about we need to give you some Pitocin because you're hypotonic. To which she said, pitocin? No. Social media said, I can't do that because pitocin is evil. So we again took a deep breath and said, wait a minute. You've kind of stalled. You kind of have to do something here. And Pitocin is standard for augmentation. To which she replied, no. What?
- [01:55]
Michael
I said, no. Why not? I don't want to.
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Dr. Chapa Zobichyn
Yep, it was kind of weird. I'm like, well, you can't just sit here at 6cm ruptured and not doing anything. We got to do something. To which she said, ah, but I do have something that we can do, because I read also online that I can take a pill called misoprostol, and that is safer than Pitocin. Yeah, this was a real thing, guys. So it opened up the door to this wonderful discussion of, well, while we use Pitocin in the US for augmentation, misoprostol, otherwise known as cytotec, is mainly done earlier in the game for cervical ripening and or for induction to get the process started. But you've already started, so you need augmentation. So this was a wonderful debate about is misoprostol. Can we use Cytotec not just for ripening, not just for induction, but for augmentation and after the active phase of labor? It's a brilliant discussion. And the truth is, while it wasn't our protocol in our institution, it actually is evidence based. There is some data to that. We're just not familiar with it now. This is why I think it's interesting why we're doing this as an episode. Number one, I'm not advocating that if somebody stalls in the active phase to go straight for the side attack, especially in what we're going to discuss here as an oral solution, we which is very SOGC friendly. That's the Society of Obstetrics Gynecology Canada. Cause that's actually in their guidance we're gonna talk about in this episode. But just to be aware that sometimes just because we don't hear about it or we don't use it very often doesn't mean it's not evidence based. So misoprostol for labor augmentation in the active phase of labor. Is that evidence based?
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Michael
No, it's not.
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Dr. Chapa Zobichyn
Yes, it is.
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Michael
No, it's not.
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Dr. Chapa Zobichyn
Yes, it is.
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Michael
No, it isn't.
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Dr. Chapa Zobichyn
Yes, it is.
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Michael
No, it is.
- [03:52]
Dr. Chapa Zobichyn
The truth is, yes, it actually is. It is totally evidence based. Although it's not the standard for sure in any labor and delivery unit. Why? Because our standard go to for augmentation, of course is Mitocin. But we're going to tackle this. Is oral misoprostol okay for labor augmentation in the active phase?
- [04:15]
Michael
No, it's not.
- [04:17]
Dr. Chapa Zobichyn
Yes, it is.
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Michael
No, it's not.
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Dr. Chapa Zobichyn
Yes, it is.
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Michael
No, it isn't.
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Dr. Chapa Zobichyn
Yes, it is.
- [04:20]
Michael
No, it isn't.
- [04:21]
Dr. Chapa Zobichyn
Yes it is actually evidence based. I found this very, very interesting. So our patient finally did allow some Pitocin. Just FYI because it wasn't our protocol to give Cytotec after the active phase. But she technically was correct. It is absolutely a thing. Even late in the active phase of labor. So oral Cytotec solution for labor augmentation. It is a thing. We're going to cover it in this episode. This is Dr. Chapa's ob gyn, no spin podcast. Me and Vincent would have been satisfied with some freeze dried taste. His choice, right? Podcast family, you never have to settle for anything in life. Nor should you. And that includes your cup of coffee. We're super thankful still for our partnership with the strong coffee company that is striving to reach our natural greatness. Strong Coffee Company with 20% discount code. Unique to our podcast family found in our Show Notes. Again, go to our show notes for a 20% discount whatever you buy through the Strong Coffee Company and kick up your cup of coffee a notch. Again, thankful for the strong Coffee Company 20 discount with the link in our show notes. Even though he is perfectly one dimensional in most of his roles, I do like me some Christopher Walken because I think he's just so strange and his delivery of lines is just so bizarre. But anyway, I'm telling you, initially when we offered this patient, you know, oxytocin for labor augmentation, because that's what we do, that's standard, pretty normal, nothing outlandish, I'm telling you. I mean, she harnessed this weird Christopher Walken response and I literally saw his face on her body.
- [06:57]
Michael
No.
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Dr. Chapa Zobichyn
What?
- [07:00]
Michael
I said no. Why not? I don't want to.
- [07:05]
Dr. Chapa Zobichyn
Now, before we go any further, let me. Again, as I said in the intro, I'm not advocating for Cytotec in the active phase. I'm not saying that this is gonna replace Pitocin, but I am doing this as a commitment on what we do on this show, which is to let you know what is evidence based, what is sometimes a little controversial and what is out there. And technically this patient was correct. Yes, we could do Cytotech in the active phase. That's a thing. Even in the SOGC guidelines, it's a thing. Now, even though we follow acog, it's okay to know what other countries do. Perfectly okay, because it just tells you how medicine is both the science and as I said many times before the art. So nothing wrong with looking at another country's guidance. And that's what we're going to do in this episode now. And to be clear, once again, we got to know our contraindications. Obviously never going to do this in a patient who's had transfundal or trans myometral surgery. Not going to do this if there's some kind of already ill response to the medication. And traditionally I got to stick on the most standard practice here. It's for cervical ripening and or induction, but augmentation, it is indeed a thing. Now this is weird because some time ago one of our podcast family members also sent me a message about this very issue. And as we get into the data here, and this is going to be very quick. All right, I'm just going to read you the SOGC guidelines which say, hey, you can do pit and you can do an Aram or you can give her Cytotec all for Augmentation, even in the active phase, it's going to be okay. And I'm going to give you the data that where they base that, that recommendation on. But, and the other issue goes with static or titrated dosage. Now in the US we pretty much do static dosages, 25 micrograms per vagina every three to four hours based on your hospital protocol or 50 milligrams 50 micrograms every four hours based on your hospital protocol. And that's regardless of route of administration. But traditionally it's mainly used either oral or vaginal. That's a static dose, one set dose, repeat over a set amount of time up to a maximum. Okay. However, there is something called a titrated dose which is much more common with the oral formulation. Now what is novel in this? Guys, as a take home discussion to talk amongst yourselves, put this as part of Journal club. This isn't just about the pill. Putting a pill in your mouth and swallowing it, which is fine, but. But this is actually about dissolving a set amount of micrograms in liquid, a small amount of aliquots of just regular old water, and then taking that every two hours as increasing dosages up to a max to try to augment labor. This is very well a thing and it's very clearly outlined in the Society of Obstetric Gynecology and Canada. So if a patient offers, you know, another route of care that you may not be used to, first thing is, is she nuts? Because we got to address that. Second is, she's not nuts. Take a look at the data. Just because you haven't heard of it does not mean it's not evidence based. And so if you offer a patient potion and she politely declines.
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Michael
No.
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Dr. Chapa Zobichyn
What?
- [10:19]
Michael
I said no. Why not?
- [10:22]
Dr. Chapa Zobichyn
I don't want to then go through these alternatives and maybe bring it up to your hospital policy and procedure department as an alternative. All right, So I think I've set it up enough. Again, not advocating for this as routine, but the question is, can that be done? Is that evidence based? And the answer is absolutely yes, you actually can. There are two RCTs from the green Journal that took a look at this. Comparing titrated oral misoprostol versus intravenous oxytocin for labor augmentation, not for ripening, not for induction, for augmentation. And they started at 20 micrograms per hour and then increased to 40 or sometimes it went up to 30. So the point is they went up into this step ladder approach up to about 50 micrograms at a time. Now, the catch is, the catch is, while this definitely works, there's again no hospital policy or protocol universally accepted in the US for this. So that's still needs further study. However, the evidence that supports misoprostol cytotec for labor augmentation is absolutely well established. There was an RCT that included patients. Guys, listen to this. At 4 to 8 centimeters. Now, 4 centimeters is still latent phase. However, when this study was done, which was, and it was accepted in the green journal in 2011, remember that 4cm was then called the active phase of labor. Didn't move up to 6cm until safe prevention of the primary C section. And that obstetrical care consensus number one was released around this time to just slightly afterwards. Right. So this was still around the time when 4cm was considered the active phase of labor. So this was an rct and it randomized patients to either pitocin fragmentation or oral side attack at 4-8cm. That was in 2011. The year before that, another trial looked at doing the same thing up to 9 centimeters. I mean, what? Yeah, I mean, it's like you're so close, you're like rim. I can feel a little rim of cervix around. I'm going to give you a little 20 micrograms of misoprostol hourly and then you could increase to 40 micrograms. And guess what? You know, nothing bad happened. They had similar rates of vaginal delivery oxytocin compared to oral titrated misoprostol. That was in 2010, also in the Green Journal. Crazy. Crazy. So again, very clear, I'm doing this for academic discussion. I'm doing this to show you that, yes, just because we don't typically do something doesn't mean that it's nuts or not evidence based. It is very well evidence based in the data. And so much so it's actually in the SOGC guidance from 2023. Now, it'd be nice to have more data. We do have those two RCTs. We do have the guidance from SOGC that shows. Look, Mr. Prussel has been around for a long time. Even in the oral route, there's no absolute contraindication in the active phase. And this seems to work. So why not. However. However just put the brakes on it because I don't want you to do something outside of your hospital policy. But it is an interesting point for discussion and. Or for patients who decline Pitocin because social media tells them that it's evil. It's not evil. But although it must be respected, then perhaps, perhaps this is a side door to get labor going when needed. Okay, so again, not for everybody, but for those that need augmentation, yes. Misoprostol, typically in oral or in dissolvable plain water, has data that it works. So very quickly, let me just give you the synopsis from SOGC from 2023. And it states oral prostaglandin E1 or intravenous oxytocin with amniotomy can be done as a preferred agent of induction when the bishop score is seven or greater. So I know what you're saying. Well, wait a minute. Huh? Where is that? In the active phase. No, no, no. Well, I'm going to get there. This is just about saying a bishop score of seven or greater, which still means it's a favorable cervix. Most people go straight to pitocin. But even though this implies latent phase, the point is, just because your bishop score is greater than seven, you don't have to stop or no longer offer prostaglandin E1. And in this case, they offer oral prostaglandins now, just to fairly represent. To fairly represent. To represent fairly. What is it, Michael? Represent. Represent fairly. Fine, look, sometimes English is a second language. Just to represent fairly the SOGC guidance, which is number four, three two letter C, 432C, which is induction of labor. Again, just throwing this out there. Food for thought, fodder for discussion. Fodder for discussion. Look how interesting this is because the whole thought in the US which is very again, ACOG culture, which is fine. This is. Okay, again, the most traditional is IV oxytocin in the active phase or, you know, arom or something else. And we kind of stop oxytocin like it's somehow contraindicated. It is not. It's just not what we typically do. So here's what they say. This is recommendation number six and their summary statements under Mr. Prostol under their guidance number four, three, two. See, just. Again, not saying that we're doing this here, just letting you know how. Just because we don't do it doesn't mean it's not correct. Quote, once active labor has commenced. Oh, here we are. So here we are. Once active labor has commenced and or the membranes are ruptured, the clinician is not required to switch to from misoprostol to oxytocin, as continuing with misoprostol may be more effective. That level of evidence was considered, quote, end quote, high End quote. Not high as in do be high. High as in high quality. Okay, so is that wild or what? Let me just read that again without the dramatic pauses just to throw that out there. If a patient says, I want to continue misoprostol in the active phase. Hey, I don't wanna do anything against my policy, but I'll bring this up to nurse management if I get the okay, we'll do this together, honey. Why not? Let's do this. As long as we realize that the lower the dose, the safer. To prevent hyperstimulation. Tachysystole. Because hyperstimulation is now being replaced with tachysystole with a qualifier of what the fetal heart rate tracing is doing. Okay, so absolutely. The reason why we like Pitocin more. Let's call it what it is. It's historical. It's. It's ease of use. Meaning you turn off pit, it's kind of gone. However, the rebuttal to. Well, I can't take away Cytotec if it's in her system. No, but you can stop the contractions. You can give her terbutaline to try to halt them. So there are interventions there that are available. Quote, once active labor has commenced and or once the membranes are ruptured, the clinician is not required to switch from misoprostol to oxytocin, as continuing with misoprostol may be more effective. Again, just found that to be very, very interesting. And they make the discussion here. They make the point that in those who need augmentation, if the car is rolling, but is rolling very slowly, either pitocin or misoprostol can be considered because there's no clear advantage, there's no clear winner in this game. That is according not to ACOG or smfm, but to sogc. Just throwing it out there again for introduction. So as we get ready to wrap this up, I just, again, very quick, very focused. Is there data for this? Yes. Is there level one evidence for it? Sure. Even up to 9 centimeters. So if a patient is refusing oxytocin because TikTok told her it was evil, no beef with TikTok or some other social media channel. And you've got to do something, maybe perhaps oral side attack, either as a tablet form or in a dissolvable form at about 25 micrograms, which is how we would score our typical tablet in the U.S. perhaps that's the thing. But you just can't let her sit there saying no forever.
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Michael
No.
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Dr. Chapa Zobichyn
What?
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Michael
I said no. Why Not I don't want to.
- [19:14]
Dr. Chapa Zobichyn
I think it's fascinating. That's why we have representatives from other professional societies who, you know, sit at leadership positions within the acog. That's why CDC has different members and different panels from different disciplines to try to give information and advise, because we need to see what other people are doing. Who was one of the first that said, hey, we're not doing late preterm steroids because we got issues added to Royal College, other countries as well. So it's important to know what other people are doing and how they manage labor because once again, labor and medicine is both a science and an art. Podcast family. I think I've done what I'm supposed to do. I just thought it was interesting. And to our podcast family member, if I remember right, which is tough because I got so many open drawers and in the brain, you have no idea, guys. It's like, you know, your kitchen, everybody's got that one junk drawer. I've got like 12 of those in my hippocampus. Right. I mean, a lot of stuff up there rattling. I think, if I remember correctly, I think that podcast family member who sent me that question, I believe she was Canadian, I want to say. I think so. I'll have Michael look back through the messages, but so interesting. And I think the question was something like, have you heard of oral titrated misoprostol for labor augmentation? Absolutely. It does not have to be a hard and fast. No. Just because they're in the active phase of labor. No. What?
- [20:45]
Michael
I said no. Why not? I don't want to.
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Dr. Chapa Zobichyn
Podcast family, as always, we're thankful for you. Thanks for your support. Thanks for putting up again with the silly as well as the high hitting evidence based data. We're thankful for you. Now that we've done all that, Michael, let's take it home. Foreign. This has been Dr. Chapa Zobichyn. 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.