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- [00:00]
Sam
Foreign.
- [00:24]
Co-host (possibly a medical expert or clinician)
We are back. So in this episode we're going to tackle something that hasn't even come out yet. Now, as quick point of reference, we're recording this on February 21, 2025, although I think it'll probably come out either tomorrow. What is tomorrow? Saturday or Sunday? Anyway, it's going to be coming out soon. But this publication hasn't even come out in print yet. This is ahead of print. It's going to be coming out in March of 2025 in the gray Journal. That's the American Journal of Obgyn and is a prime example, as we've covered many times before, of why clinicians get so frustrated with medicine. Because it's the he said, she said do this or don't do that and then back to do this argument that we've talked about many times before. That's what to do with a patient who wants a TOLAC at term. Should we do an induction of labor or allow expectant management for spontaneous labor? This new population level data, which is coming out in March, is totally in contrast to ACOG's guidance from 2019 in terms of the results stated. So once again, this is why it's he said, she said and in direct conflict to what is referenced in the ACOG guidance on trial of labor after C section from 2019. It's interesting. That's our topic. So hang in there and we'll be right back.
- [01:49]
Sam
SA.
- [02:19]
Co-host (possibly a medical expert or clinician)
This is Clinical Pearls.
- [02:42]
Sam
Sam.
- [03:25]
Co-host (possibly a medical expert or clinician)
Hey.
- [03:25]
Ryan Reynolds
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- [04:55]
Co-host (possibly a medical expert or clinician)
Yeah, this is definitely why people get frustrated. Wait, you do want me to induce or you don't want me to induce? Are we supposed to do the 39 weeks offering or just wait for them to go into spontaneous labor? Is it the arrive trial or is it not the arrive trial? I mean, there's so many things, right? The short of it is this is why medicine, it shouldn't get you frustrated. Actually should get you pretty fired up that it really is a science on the one hand and an art on the other. Now, that statement, science and the art is so true about what we're going to talk about in this episode because, yeah, so far, so good for the ACOG guidance, which is practice bulletin number 205 from February 2019 that discusses the success of of a trial of labor after C section when it's induced versus when it is vaginal spontaneous labor and direct contrast to what we're going to talk about, which is coming out in March. So first of all, let's start there, because in 2019, it was in February where ACOG released their practice guidance. Again, we just stated it, 205, which is vaginal birth after cesarean. All right, so VBAC, vaginal birth after cesarean section. Well, there's a whole subsection on there which is induction and augmentation of labor. Okay, now to be very clear, remember that outside of prostaglandins, yes, you can do an induction of labor with a tolac, as long as it's not, obviously, a classical C section. No other contraindications to vaginal delivery. Everybody gets that. So that can be either Pitocin. It can be an amniotomy or a balloon induction. Okay, so we get that. However, I want you to read. I want to read this thing to you directly from this guidance in terms of success rates with induction compared to spontaneous labor. Okay? And then we're gonna get into this new publication coming out in March, because once again, this is why. And I get it. Things get a little frustrating based on who you read. Okay, so this is the guidance from 2019, February 2019, talking about success rates with induction compared to those who have spontaneous labor. Quote. Induction of labor remains an option for women undergoing tolac. And however, the potential increased risk of uterine rupture associated with any induction and the potential increased possibility of achieving VBAC should be considered. End quote. All right, so let's stop there for a minute. So induction, yes, can definitely do it. However, there is a potential increased risk of rupture with induction compared to spontaneous labor. Okay, so again, I'm reading from the 2019 guidance. I haven't gotten into the new stuff yet. And so let me give you this here briefly. Quote, when compared with spontaneous labor. Here it is, guys. Induced labor is associated with a lower likelihood of achieving vbac, end quote. Now, there's a lot there because it depends on what the Bishop score is, if she has a previous history of a successful vaginal delivery or not. So there's a lot of factors that go into this. Right. But in general, as a big bucket, According to the 2019 guidance, which is guidance practiceability number 205, yes, you can induce. Yes. Maybe potentially a slightly increased risk of rupture because you're forcing the uterus to go into something that's not ready to do. But even though it's still acceptable to do that. I'm just saying. But again, this is right out of the guidance. And maybe a slightly decreased risk of achieving successful VBAC compared to spontaneous labor. All right, that's not my opinion. That is exactly. Exactly what is in the guidance from 2019. Okay, now this is. Induction has nothing to do with augmentation. That's a separate issue. So, you know, they get a little hypotonic at around 5-6 cm or whatever. That's a different issue. This is induction of labor because this is what the March new study is looking at. Should we just wait for them to go into labor, or should we induce them and really give them more kind of directed counseling for that? Remember, patients get to choose, so we shouldn't be forcing them to do one way or the other. But in this new publication, which is from March 2025, the. The title of which is induction of labor versus expected management among low risk patients with one prior cesarean delivery, end quote. That's what they were looking at, okay, From a population level, from the US Just looking at vital statistics birth certificate data. So not medical records, guys, right? This is what. What is filled out by the. By the clerk or whatever, when a patient delivers in the hospital. And then they say, here, sign this, make sure everything is right. And then the patient signs it. That's what they looked at. So there is some limitations there, because maybe somebody coded something incorrectly. Maybe something was in an augmentation versus an induction. Whatever. The point is, this is a vital statistics birth certificate data set that spanned the years 2016 to 2021 here from the U.S. okay, so we can get into that in a minute. But just my point is, remember that in 2019, ACOG says totally, you can induce. Not an issue. We should fight for TOLAC when it's safe and acceptable as a candidate. But of course, you know, it's always better for them to enter into spontaneous labor. All right, so having said that, remember that. Okay, Same thing with uterine rupture. There tends to be a slightly higher risk of uterine rupture with induction versus spontaneous labor, but yet still in the realm of allowable. Okay, so remember that. So do better with spontaneous. Then the second best is induction, and in terms of rupture, higher with induction and. And then better to have spontaneous Labor. That's from 2019. Now in this new publication that is from the United States. Let me just read you very quickly their study design. Then we'll get to the results because I remember, I'm trying to tell you this quickly. So I'm comparing it to ACOG's guidance that last came out in 2019, and then telling you what's coming out next month, actually in about, what, 10 days or so. But this guidance has not been replaced. It's still active. Actually, it was just reaffirmed August of 2024, which is practice bulletin number 205. So the college just last fall said. Yep, looked at it. Nothing's really changed. Everything in there is legit. Okay, so sitting on the ob, Obstetrics care committee, I get how this works. You got to go through all the main details. Anything new changed, is it still valid? Yes. Puts a check off mark, boom, it gets the reaffirmed, and then it goes off. So this was reaffirmed just in August of 2024. So that's six months ago. Okay. And that's fine because this new publication just came out. So let me read you this study design and then we'll take a quick break and I'll tell you the results and then we're going to wrap it up. So here it is. Quote, this cross sectional study analyzed 2016-2021. U.S. viral statistics, birth certificate data. Yeah, just told you that. They keep going. Quote, individuals with vertex singleton pregnancies and one prior cesarean delivery were included. Excellent. Quote, patients with prior vaginal deliveries, delivery before 39 weeks and 0 days or after 42 weeks and 6 days. And medical comorbidities were excluded. Now I like that because that's a big factor that's going to influence success. Right? We just said that before we got into this new publication. Prior history matters. So this is, hey, this is your first go around at tolac. You've had one prior section, it's a singleton, you've got no other issue. We don't want anything else getting away. It's not like a ten pound kid. You don't have diabetes. So all of those are excluded. It's just good old fashioned, low risk. One prior section, no prior vaginal deliveries. Let's see what happened. So the primary outcome was, quote, induction of labor at 39 weeks, 0 days to 39 weeks and 6 days was compared to expectant management with delivery from 40 weeks and 0 to 42 weeks and 6. The primary outcome was. Did it work? Vaginal delivery. Okay. But they also threw in some secondary outcomes which of course you would figure are super important, like maternal and neonatal morbidity. The maternal morbidity included things like uterine rupture, operative vaginal delivery, peripartum hysterectomy or ICU admission and transfusion. Makes sense. So everybody Good. That's our setup. When we come back from this very quick little break. We're going to get into this because if everybody just could get along and speak that. Don't I know that. If everybody can just get along, I'm going in there. But isn't it true? If we could just have the same information, that would be great. But sometimes medicine is more of an art than a science. So hang on, we'll be right back. And then we're going to give you the results of this new publication.
- [13:49]
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- [14:18]
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- [14:59]
Co-host (possibly a medical expert or clinician)
Hey, we're glad you're part of our podcast community. You're listening to Clinical Pearls. All right, we are back. So remember that this is a US birth certificate data mining study from 2016 to 2021 in a very niche population pat undergoing TOLAC with one prior C section. No other medical issues that are vertex and that fit all the inclusion criteria that we've already discussed. Okay, so from 2016 to 2021, in that time frame, there was 198,797 patients who went into this study. So not hundreds of thousands, not half a million because it's very niche. And again, only covered 2016 to 2021. Now here's what's super interesting. Of those 198,797, 87% were expectantly managed and had a delivery between 40 weeks in 0 up to 42 and 6. Now I get very uncomfortable letting the patient go past 42, but maybe that was part of their desire because they can pick whatever they want. Patient autonomy. But wow, 42 weeks and six. Now that's just what the allowance that they used, although you know, very few went that far out. Okay, but that's just the bucket to catch everybody even past or within that 42nd after that 42nd completed week. Okay, so 87 were managed expectantly. Now was that patient desire? Was it physician influence? Was it physician preference? Like we don't want to toe lack mess with an induction in somebody with a scarred uterus? I don't know. But 87%, that's interesting. Just from 2016 to 2021 compared to that underwent induction of labor from 39 and 0 to 39 weeks and six days. Okay, so definitely not equal populations here. Vast majority allowed to have expected management, which I kind of like. No reason to force things if the uterus already got little injury. Okay, Got little scar. No reason to push things unless there's something else. So I'm totally okay. I. I offer the patient both. You can wait or we can induce. And I give them all of the data as share decision making. And this is why we do share decision making. Because unlike the guidance from 2019 that said induction seems to have less success, induction seems to have higher risk of rupture. That's not what this found. Okay. Now it's just in national population database, but again, just looking at these years for those numbers. So maybe in populations that weren't equally matched in terms of expected management and induction, but nonetheless, I'm going to give you the results, which is not what the ACOG practice bulletin guidance says. This is why medicine is an art. Now, I'm going to explain this why that is at the end. Remember, this is not actually looking at the patients themselves or the individual records, just the birth certificate data. All right, fine. So here it is. Quote, of these individuals, 13 underwent induction and 87 were expectantly managed. Fine. In adjusted analyses. Good, because we want to control for other factors in adjusted analyses. Here it is, guys. Patients induced at 39 weeks were more likely to have a vaginal delivery when compared to those expectantly managed. It was 38% versus 31.8% with an adjusted odds ratio of 1.32. Now, the confidence intervals were above 1, but not. And it was a very narrow interval of 1.28 to 1.36. So, yes, it's on the side of benefit for induction, but not like a whopping benefit, but nonetheless, 38% compared to 31.8% in the induction. So let's stop there for a minute. So, a lot of words short of it is this is exactly opposite of what is in the ACOG practice bulletin from 2019, which is what I read you. Those who have induction tend to have slightly lower chance of successful vbac. According to this quote, patients who had induction were more likely to have a vaginal delivery compared with expected management. End quote. Well, isn't that special? Again, don't get frustrated. I'm going to give you an exam, tell you at the end why this matters. Remember, the slate was clear. No medical comorbidities, no previous vaginal history, just one prior section. But we have a direct contrast to what we just read from 2019. So let's continue, and they're going to start wrapping this up. Quote. Among those who had a vaginal delivery, induction of labor was associated with increased likelihood of operative vaginal delivery and the maternal Morbidity composite occurred in 0.9% in both the induction and the expectant management group. In other words, rates of uterine rupture, peripartum, hysterectomy, ICU admission were all relatively low and did not differ between groups. So that's the good news is it didn't seem to increase rupture because rupture is pretty darn rare. So you probably don't have enough sample size to find that. But that is reassuring. So two big contrasts here. Number one, it did not seem to increase rupture rate. That's good. And number two, induction seemed to increase the risk of successful vaginal delivery. Well, now that we get ready to. Now we've presented that. Let me just break this down before we get ready to wrap this whole thing up. Super complicated. Because even though nobody here in this study had a previous vaginal delivery, it's hard to group everybody in under one bucket of induction because an induction of labor with a bishop score of 55 is different than an induction of labor with a bishop score of two. Does that make sense? Also, the reason for the primary C section was important. All of that. Those are all factors that need to be taken into account. So my point here isn't to confuse anybody. Number one is to highlight brand new publication which is coming out in March, because that's what we do. Number two, put it in clinical perspective. And then number three, put it against what we already know. Well, we already know, which was reaffirmed August of 2024, is that it's always best for the patient to enter spontaneous labor by herself. But according to this publication, if they want induct, thankfully complications were no higher. And actually it seemed to be that induction gave a little bit higher rate of success. All to say whatever the patient chooses seems to be the right one. So our job should be to be supportive, educational, and say you really do have two options here, and it's a he said, she said about which is the right way to go. So when they both can agree the patient is the referee. Is that interesting or what? Again, we've highlighted a new publication. This is coming out March 2025. The title is induction of labor versus expected management among low risk patients with one prior cesarean delivery. I hope you found that interesting because I sure did. When I read that, I'm like, well, that's actually not what the college says in terms of its prior guidance. So again, that's why we keep learning. That's why medicine is lifelong learning. Because just when you think you figured it out. Chances are you probably haven't. Podcast family, we really are thankful for you. Thank you for the support that you sent me through personal messages, and we'll just leave it at that. Podcast Family, now that we've done all that, let's get ready to take it home and we'll see you on another episode of Clinical Pearls.
- [22:41]
Sam
Sam.
- [23:18]
Co-host (possibly a medical expert or clinician)
Podcast family, we really are thankful for you. We hope you enjoyed this episode. We'll see you next time on Clinical Pearls.
- [23:33]
Sam
Sam, It.