Loading summary
Transcript20 lines
- [00:10]
Podcast Host
Hello.
- [00:10]
Dr. Chapa
Now don't you worry. We'll soon have you cured. Leave it all to us. You'll never know what hits you.
- [00:16]
Podcast Host
Goodbye.
- [00:17]
Dr. Chapa
Goodbye. Drips up. Injections. Can I put the tube in the baby's head? Only if I can do the episiotomy. Okay, legs up. Come in. Come on in. That's it.
- [00:28]
Podcast Host
Jolly gun.
- [00:29]
Dr. Chapa
Come on.
- [00:29]
Podcast Host
Come on.
- [00:30]
Dr. Chapa
Spread around there. Who are you? I'm the husband. I'm sorry, only people involved are allowed in here. What do I do? Yes, what do I do? Nothing, dear. You're not qualified. Leave it to us. What's that for? That's the machine that goes bing. You see, that means your baby is still alive. And that's the most expensive machine in the whole hospital. Yes, it cost over three quarters of a million pounds. Aren't you lucky? The administrator is here, Doctor. Switch everything on. Morning, gentlemen. Morning, gentlemen.
- [01:11]
Podcast Host
Morning.
- [01:13]
Dr. Chapa
Very impressive. Very impressive. And what are you doing this morning? It's a birth.
- [01:19]
Podcast Host
Ah.
- [01:20]
Dr. Chapa
What sort of thing is that? Well, that's when we take a new baby out of a lady's tummy. Wonderful. You know, nowadays. Ah, I see you have the machine that goes bing.
- [01:32]
Podcast Host
This is my favorite. All right, so I'm sorry, but Monty Pythons, British humor. We've got plenty of podcast family members across the pond. Look, you either get British humor or you don't. And I'm kind of in the middle. Some of that is beyond my head. But Monty Pythons was so. I mean, I was like super young kid, you know, when this thing came out, I was like, what is happening with this? Is this how adult humor is? And it's so weird. But I do remember the meaning of life. The birth clip from Monty Pythons. Just bizarre. But it does highlight the complexity of birth. I love when they say, oh, well, you don't do anything, ma'. Am. You're not qualified. We will do everything. Oh, my goodness gracious. Ought to say birth is complicated. And it's even more complicated. And after a C section, that's where we're going. I think that may have been one of our longest unrelated intros ever, Michael, but you had to do a little Monty Pythons. Come on. So what we're going to talk about is Tolac, Pitocin and the use of internal monitors. All right, this is the latest information because something just got published out of ajog mfm. That's not the gray journal. That's the pink journal. And that came out at the start of this month, January 2026. This is a new systematic review and meta analysis that's taking a look at oxydocin dosing, oxytocin dosing during trial of labor after C section, and how we can minimize the risks of uterine rupture. So just set the stage clearly right at the beginning. ACOG says after one and reasonable up to two. The patient accepts the risks reasonable to offer TOLAC trial of labor after C section, after 1 low transverse or up to 2 low transverse C sections, knowing if, of course, that the risk of uterine rupture is higher after 2 low transverse C sections. Actually, it's about double the risk of one prior C section. But overall, the absolute number is still very, very small. So it goes from about 0.5 maybe to 1%. Some say no, it's more like 0.9% after 1C section, and then you double that to about 1.8%. So close to 2% after 2. But the numbers are all over the place. The highest that I have seen after two C sections and a TOLAC is a rate of uterine rupture of about 3.5%. So it depends on how you look at it. 3.5% is too high for me personally, but again, you know, 96% chance nothing's gonna happen. The overall safety is still there after one or two low transverse C sections, if the patient understands the risk, understands what's at stake, and is willing to take that risk. Okay, so again, ACOG says one or two prior low transverse, transverse C sections, it's okay to tollec with shared decision making. Low vertical C section is still in the non contractile. And that's fine as long as it really is in the low vertical area. Whereas any transfundal uterine surgery, including of course, myomectomy or a classical C section, is a contraindication. Okay, so just setting that stage. Of course, that's nothing new. That goes all the way back to ACOG's original guidance on this, which was number 184. That's practice bulletin 184. That's vaginal birth after cesarean. Back originally in 2017, though it's been reaffirmed. So just setting the stage here on who can tolac. The question that we're gonna answer in this is two things. And again, always true to form, we get a lot of ideas from real events. We have a patient actually on the board right now who has two prior C sections, who wants a tolac, who we did an amniotomy or trying to hold off on Pitocin because that would be an additional risk. And we're trying to get her delivered without resorting to another section. So we're gonna answer two questions here based on our real world contact and of course, what's brand new in the data? Cause this is brand new in the data, and that is the systematic review and meta analysis on oxytocin dosing during trial of labor after cesarean to minimize the risk of uterine rupture. We're very quickly gonna answer that. But secondly, we're gonna answer this question that the resident team and I discussed yesterday. Are internal monitors any better than external monitors at seeing early signs of rupture in a tolac? All right, so the two questions we're going to answer is, what about Pitocin and tolac? Well, the short answer is yes, it increases the risk in every study. Pitocin always increases the risk of rupture over spontaneous labor for those with a scarred uterus. And the risk really depends on number of C section. And then two factors that we're going to address here based on this new Pink Journal meta analysis that just got published. And then the second question, of course, is, is, is the use of internal monitors, an FSD and an IUPC any better at detecting early signs of rupture as composed to external? Okay, so we're going to talk about those things. Our points of reference are going to be three things. The first is that Pink Journal article that was just released January 2026. The second is, as we've mentioned, ACOG's practice bulletin number 184 on vaginal birth after cesarean. And then we're going to talk about ACOG's clinical practice, the CPG number 10 that came out not long ago, just October of 2025, which we also covered on this show, dealing with interpartum fetal heart rate monitoring. As we discuss internal versus external, both of those fall into the banner under the umbrella of continuous fetal monitoring as opposed to intermittent fetal monitoring. Okay, so we're gonna briefly touch on that. So let's just, while we're still in the intro, let's just make it clear TOLAC needs continuous fetal monitoring. Okay, so while ACOL does say that intermediate intermittent fetal monitoring is a thing for low risk patients who are not on Pitocin. All right, so Those are the two caveats which we've covered, guys, back in October 2025, when the CPG came out, we did that synopsis on intrapartum fetal heart rate monitoring, that clinical practice update back then. But if they ask if Anybody ever asks you, what does ACOG say about continuous fetal monitoring? Well, very easy. Definitely increases interventions and procedures, definitely decreases early onset neonatal seizures, but really hasn't caused a dent in long term neurological issues. And yes, the issue is, can it predict intrapartum death? Well, that's the most catastrophic thing. That's the most rare, but, yeah, because you would pick up fetal heart rate deceleration, which is very, very pathognomonic of uterine rupture. Although it doesn't happen all the time, but it happens 70 to 80% of the time where the first sign of uterine rupture is severe fetal bradycardia or a drop in the fetal heart rate. Okay, so does ACOG allow intermittent fetal monitoring? Absolutely. For the low risk patient who is not on oxytocin. For the low risk patient not on oxytocin. But for those that are considered higher risk and TOLAC is a higher risk, or those who are at higher risk of intrapartum fetal death? Yes, those patients should have continuous fetal monitoring. Okay, the question is, when you go a step further than that, like for tolac, does that continuous fetal monitoring, is that any better if it's internal as opposed to external? So those are what we're going to cover. Pitocin dosing and then continuous fetal monitoring. Are internals any better than external fetal monitorings for the TOLAC patient? All right, I think I've set it up enough. We talked about Monty Pythons and a machine that goes ping. And now let's get out of the intro. We'll be right back. This is Dr. Chapa's ob gyn. No spin podcast.
- [10:20]
Dr. Chapa
Oh, the bulb is dilating, Doctor. Oh, yes, there's the head. Yes. 4 cm, 5, 6 cm. Lights. Amplify the ping machine. Masks up. Suction. Eyes down for a full house. Here it comes.
- [10:36]
Podcast Host
And frightening.
- [10:38]
Dr. Chapa
Kill. And the rest.
- [10:41]
Podcast Host
Toes.
- [10:43]
Dr. Chapa
Show to the mother. That's enough. Right. Sedate her, number the child, measure it, blood type it, and isolate it. Okay, sure.
- [10:55]
Podcast Host
All right. So many things factually incorrect with that whole thing. Oh, she's dilating. 4cm, 5cm, 6cm. And then the kid is delivered. That little chopping sound that you heard was a true, like, butcher's knife cleaver chomping the umbilical cord after birth. Oh, my goodness. Monty Python. What are you going to do? All right, so back to the real stuff. In the pink journal that just came out for January 2026, this systematic review and meta analysis had the question that we all should be considering for tolac, does Pitt increase the risk of rupture as opposed to spontaneous labor? That's number one. And in all of the data, as far as we know. And it's in the ACOG guidance. Yeah, it does. Now it rises a little bit, and at some point you got to do something. Just can't let her sit there. But, yes, based on most of the data, it is true that oxytocin administration is consistently associated with a higher risk overall of uterine rupture across most analyses compared to spontaneous labor. That's just a given, and the patient needs to know that, and we need to document that. Just a quick two sentences. Hey, she stalled. She understands the risks. We got to do something. She really wants to try vaginal delivery, doesn't want a C section, so we're doing Pitocin, even though the risk of rupture seems to be a little bit higher. Okay, so, yes. Does Pitocin increase the risk of urinary rupture in a scarred uterus as opposed to spontaneous? Yes, but you've got to do something, and that's called shared decision making. The question is, once you've accepted that is, does the protocol kind of matter or what matters here? How do we minimize the risk of uterine rupture with oxytocin in a tolac? And very fittingly enough, that is the title of the systematic review and Meta analysis from January 2026. The title is Oxytocin Dosing during Trial of labor after Cesarean to Minimize the Risk of Uterine Rupture. A systematic review and meta Analysis. Proof that I was not lying to you. All right, so this was 21 observational studies, so let's stop right there. These are observational. Okay, so These are not RCTs. We definitely need more data, like, better, more reliable RCTs that are well conducted, large scale to really confirm and define the optimal oxytocin regimen for TOLAC care and management. But for now, we're going to do with what it is. It's 21 observational studies. The N is pretty acceptable. It's 51,000 patients. Actually, 51,000, 511. Okay, so five 1, 5, 1, 1. That's a lot of patients. 51,000, 511. So short of it. Let's just say this very quickly. Three main takeaways here. Number one, yes, as we've already stated, oxytocin used during TOLAC consistently is associated with a significantly higher risk of uterine rupture across all analyses. And the odds ratio kind of varies, but it's around 1.94 with a confidence interval that is definitely above 1, does not CR1, and in this analysis was 1.36 to 2.77. Okay, so, yeah, so it's above 1. It's on the right hand side of 1. It's higher incidence with a confidence interval from about 1.3 to 2.7. Now, here is the catch, okay? Is it better to use a lower dose of oxytocin or a higher dose? Well, according to these observational studies. So once again, you gotta take that for what it is with some biases in there. In an observational study, it does seem that higher dose protocols, okay, higher dose protocols, especially going over 20 milliunits per minute, may enhance the risk of rupture. Okay, so there is something to keeping the total oxytocin dose less than or equal to 20 milliunits per minute. Okay, so that's the first thing. Yes, dose matters. Dose matters. The second is interval matters. Interval matters. The interval of rise, the interval of dose escalation. In this study, those who had dose escalation that was longer than or at 30 minutes seemed to lower the risk of uterine rupture, whereas those that had more shorter dosing intervals, in other words, less than 30 minutes, had higher risk of uterine rupture. Okay, so let me just read this directly. So those are the two things that we're gonna keep in mind. Okay? I'll give you the third here in a minute. So the first is, yes, dose matters. And then this one, it was greater than 20, had a higher risk number two, interval matters. So try to escalate a little bit more cautiously, a little slower so you don't bombard the uterus with signal. And then the third is total duration of oxytocin. So a prolonged amount of oxytocin also is not good. So really limit its use to when you really need it. Okay, so in short, quote, a significant association was found in some analyses only for increments that were greater than 2 milliunits per minute or had a higher protocol of 20 milliunits per minute maximal dose for uterine rupture. Both of those significantly increased the odds of uterine rupture. So both moderate, which was less than 20, and high, greater than 20. Maximum doses were significantly associated with increased odds, but a higher risk was seen at higher dosages. In other words, giving a lot of pits, bad period, but giving a lot lot of pit is even worse. Right? So limit your dose and in terms of the dosing duration, here it is very clearly. Okay, so in those who had a dose escalation that was performed at intervals less than 30, a higher risk of uterine rupture was uniformly observed. Okay, so say that again. When dose escalation was at less than 30 minutes, a higher risk of urine rupture was uniformly observed. So take home messages is, yes, dose matters. And then this one, greater than 20 million per minute total dose seem to increase the risk. Escalation of doses faster than every 30 minutes seem to elevate the risk. And then as a take home, based on all of this data and what others have said as well, is that total duration of oxytocin, the cumulative exposure of oxytocin, rather than just the initial or incremental dose alone, both of those things, or actually all three of those things, can increase the risk of rupture. These findings showed an association between oxytocin dosing during TOLAC and an increased risk of urinary rupture. Specifically, they suggest that both the timing and cumulative exposure of oxytocin rather than the initial or incremental dose alone may critically influence urine rupture risk during tolac. Short of it is try to use a longer duration, try to keep it to under 20, and try to use Pitocin for the shortest amount of time possible. Remember, we've got an episode. I think it was something like save the pit or turn off the pit or something like that, back when there was actually a time there was a pit shortage not long ago. We're trying to keep our oxytocin use, you know, very, very limited because it was an issue with the supplier and there was data. Guys, there are protocols where, like, once you get the patient out of the latent phase, into the active phase of labor, once they hit 6 or 7 centimeters, turning off the pit in some patients can keep them going. I mean, it's. You already primed the pump, the pump keeps pumping away and it keeps moving. And you may not need Pitocin the entire duration. This whole thing of you start pitt and keep it going until delivery may not always be necessary. There is data. We've covered this. Guys, go back to the archives where you can stop the Pitocin once you are in active phase. And some patients will continue, no problem. Okay, so you don't always need pit just because she's on pit. So once she hits active phase, consider decreasing since, quote, the cumulative exposure of oxytocin, end quote, may also contribute. So three things that. That affect. This is number one, dose, two, dosing interval, and then number three, the total time or exposure of oxytocin may matter. Those are the three things to consider for tolac and urine rupture risk. Again, all of those three things are balanced against. You gotta do something. So if she's just sitting there and she's been ruptured and she's 6cm and there's nothing happening, you have to have the bedside conversation of, are you okay with getting Pitocin? How bad you want to do the vaginal delivery? Or do we say, you know, you've kind of off the clock here and we're gonna be very, very judicious and not give oxytocin because of the increased risk of rupture and go for section. All of those are the right thing to do. That's how you involve the patient in care cost, shared decision making. Again, Pitocin. I'll be very clear. Pitocin and Tolac is not contraindicated. Pitocin and Tolac is not contraindicated. You can give these patients Pitocin. The catch is understand that Pitocin in a Tolac. Tolac does increase the risk of rupture, even though it's manageable. And the overall number, the absolute number, is still very low. So it's okay. I don't wanna freak anybody out. Pitocin and Tolac is okay. It is ACOG and SMFM allowed. You've gotta do something. But don't minimize this risk like just blow up that pit. I mean, remember, I trained at Parkland, man. The Parkland protocol was six milli units, you know, every 30 minutes, and then you increase by another six, up to 42. That was a lot of Pitocin, right? Now, them babies delivered, I tell you, I mean, they, like, sneezed hard. And, you know, the kid flew out with 42 million units of Pitocin hitting the uterus. But it did increase the rate of. Then called hyperstimulation, now called tachysystole. Okay, so these are the patients you probably don't want to do the Pitocin Parkland Protocol, because higher duration, higher total exposure, and especially intervals that are less than 30 minutes tend to increase uterine rupture risk. Again, this is from the Pink journal. This just came out, guys, at the start of January 2026. And for point of reference, we're still in the first week of January 2026. It is January 6th. Although this probably won't come out today, Michael, tomorrow Or so the seventh or the eighth, something like that. Because we got. I got to record this when I got chance. I'm on night service right now, so I'm awake. I got my adrenaline going. I'm trying to knock this out while I can still see straight. So I wanted to knock this out. But we are recording this within the first week of January 2026. Now, before we leave, this issue of oxytocin, pitocin use and TOLAC and risk of rupture. Remember, this is out of The Pink Journal, January 2026. But just the month immediately before December 2025, at end of year, there was a separate study, again, very similar to the findings of the Pink Journal. This was a secondary analysis of a separate observational study out of the MFM network units. This was in the Green Journal. That was by. By Tory Metz. Okay. Secondary analysis of a different study looking at the exact same issue of oxytocin use and uterine rupture at tolac. Almost identical findings. Number one, oxytocin does increase the risk of rupture compared to spontaneous labor. And while a trend was there for higher risk with higher dose, that study from December 2025 didn't identify a set cutoff. It says it looks like it could be 20, but it's hard to tell what the exact safe cutoff is. But they both agree. That study from December 2025 and this one from the Pink Journal of January 2026, that oxytocin does increase the risk of rupture over spontaneous labor with tolac, and there is a trend with higher doses and higher amounts of exposure. All right, fine. So now that we've said that, here's the question we've answered. Pitocin. Okay, we're already done with that. The second has to do with monitoring. Now, remember, when people ask you, how do you monitor in labor? The answer is very carefully. Thank you very much. I'm out. Thank you. Thank you for your question. How do we monitor labor delivery? Very carefully. That's my professional physician dad joke. But, yes, we really do. We monitor very carefully because trolacts are high risk. But if you want more detail, know that there's two kinds of monitoring. Intermittent. Which ACOG says in the low risk patient, non being augmented or induced. Why not? You can do that as long as you follow the rules of when you should check the fetal heart rate and if there's any risk. Guys, here's the catch. Any risk, according to the college of that child developing intrapartum metabolic acidosis. So that includes prolonged labor. That includes any weird unexplained bleeding. That includes chorioamnionitis. They get iai, that should kick over. That's it. That's. That's. You've already. You've left the bounds here of normal care. That should get continuous fetal monitoring. That's not my opinion. That's right. Of the guidance on fetal monitoring. Update from clinical practice guidance number 10. Right. So, yes, things that increase the risk of neonatal acidosis, and that includes iai, that should have continuous fetal monitoring. So there's intermittent, then there's continuous. If you go even further, more in the rabbit hole. The question is, are internals any better than externals for TOLAC protection? Meaning are we going to detect uterine rupture any better with an internal? Now, I trained with the old adage that a drop if you have an IUPC and boom, you automatically drop pressure in a patient in the appropriate context. Increasing pain, breakthrough pain through an epidural or weird bleeding, especially in light of concurrent fetal heart rate. D cells. That's a rupture. True. And so that's very specific. The problem is it's not sensitive at all. So because of that, ACOG says that internal fetal monitors are not routinely recommended or proven superior to external monitors just because she is toe lacking. Now, there are clear reasons when you need an internal and that's the patient is moving too much or you can't figure out anything about contraction frequency because of bmi, obesity, or there's breaks in the signal, or you need something else. Intrauterine. An intrauterine intervention, for example, recurrent variables that needs amnu infusion. So you need to put in an iupc. Okay. So adequate. This adequacy of the external signal that may trigger need for internals. Maternal body habit is that may trigger the need for internals. Need for more precise interventions for D cells like an IUPC that may trigger internals. But just because the patient is having a tolac, that is not a standalone indication for internal monitors. Now, amniotomy is different. Amniotomy can help labor progress because of the natural bathing and prostaglandins that happens with amniorexis. So that's different. Okay. I'm not saying don't arom. I mean, you've got to help these patients along somehow. So if she is kind of stalling along, amniotomy can actually help move her without the use of pitocin. That's fine. Especially with the use of pitocin. In a judicial fashion, as we've already discussed. However, if your idea is I need the AROM to put internals because it's safer for tolac, if that's your reasoning, that's not evidence based, nor is that college guidance. Right. So ACOG does not recommend routine internal monitoring for any specific patient population, except when there's a problem with the external signal quality. For external monitors, BMI prohibits adequate recording or assessment. And then, number three, there is a need for intrauterine resuscitation, including amnioinfusion. Of course, you can't do an amnioinfusion if she doesn't have an internal. So even for tolax, patients with TOLAX do not require. It is not guideline, it is not best practice to do internals, even though that's kind of convention. And people do that because they think you can get a better handle on things. But the truth is, the biggest indication of rupture is not the drop in intrauterine pressure picked up by the iupc. It is a drop in the fetal heart rate tracing, which happens based on who you read, anywhere from 70% up to 80% where there's a quick drop or prolonged bradycardia, which is associated with uterine rupture. Okay, so the intrapartum management of TOLAC does differ from routine labor in that oxytocin use should be more judicious, oxytocin use should be more deliberate and purposeful. And amniotomy definitely has a role. But internal monitors, just because they are toe lacking, are not indicated. Okay, so as of right now, as of the start of 2026, there are no major obstetric organizations or societies that have published guidance showing that internal monitoring improves the detection of uterine rupture during tolac. So I'm going to say this once again. We start closing this up. No major obstetrical organizations or societies have published evidence demonstrating that internal monitors improves detection of uterine rupture during tolac. Okay. And the reason is some of that is frequency, prevalence, skewing because the rate of urine. I told you. See how I lose the words? Guys, I am on night float. As I've already said so, I'm a little goofy and sleep deprived, but I can't go to bed. It's amazing. I'm like, I'm so caffeinated and I'm in between shifts right now. I'm gonna. I have to go down. If I can get good two and a half hours before my next shift, baby, I'M ready to go. But right now, I mean, sometimes the words leave me. Okay, sleep deprivation. But the rarity of uterine rupture, guys, because the prevalence is so low, that's why it's hard to make a guidance of this, thankfully, because uterine rupture, honestly is quite low. So. And just to give you those numbers again, rate of uterine rupture after 1, low transverse C section, ACOG says it's 0.5 up to 0.9%. After 2, you just double those. Right? So it's anywhere from 1 to like, you know, 1.8%. While some reports say it's high, 3.5%. But some of that data can be selection bias bias. So an observer bias. So are internals required for tolac? No. And it's not just ACOG saying this. There's plenty of meta analyses that have looked at this that have showed the safety of electronic monitoring as long as the signal is good from an external source compared to internal. And they're pretty much identical. Okay, so the first question is, TOLAC does not qualify for intermittent auscultation. That's a no go. It does require continuous, but whether that is external or internal should be based on usual obstetrical and care indications. Not swayed just because it is a tolac. All right, so we had two jobs here in this episode. Number one, summarize the latest meta analysis on pitocin and uterine rupture. We did that. Second, discuss internal versus external for tolac. Hey, you can do whatever you want. You can put in internals. There's no problem. Do it because there's a reason and you're looking for something that's going to help your management. But don't do it just because you're going to think you're going to pick up uterine rupture any faster or better than externals. They do not. TOLAC does not qualify for intermittent fetal auscultation. All right, podcast family, I think I've done what I'm supposed to do. I'm going to try to simmer my brain down, simmer down, take a nap, because I got to go back in a few hours. As always, podcast family, we're thankful for you. Oh, one more thing. There's a independent podcast reviewer slash group called Million Podcast, and every year they give out the podcast to look for Woohoo. And we've always been on their list. Thankfully, someone in the top 10. Well, for 2026 as podcasts to watch, I'm very thankful thank you, Million Podcasts. Again, they're not a sponsor. They didn't get any funding from us. There's no gibbies under the table for them to say this, but we were placed as number one. We beat Creoles. We beat Creogs, baby, on the list. So thank you, Million Podcasts, for that wonderful recognition. We put a lot of effort into this, even though my words sometimes leave because English, it's still a second language. Guys, you remember I was born on the barrio, right? So I was born on the border, not by the restaurant on the border. I mean, truly on the border of Texas and Mexico. So, you know, my Spanish came first, and then I learned English, and then I finally learned Texan. So all to say, where the hell am I going with this? My producer is giving me the signal to be quiet. Thank you, Michael. You're so caring. All right, let's be done. Let's be done. Thank you, podcast family. We love you. We thank you for being part of our podcast community. I'm getting off. Stop it. Geez Louise. Do you all know that the cut sign, the thing across your neck, that or he's telling me he's going to kill me. Be done. Yes, I'm going to be done. Geez, Louise. We'll see you next time on the no Spin Podcast. Foreign. This has been Dr. Chapa Zobi Gyn. No Spin podcast. Podcast family, thank you for your support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast.
- [33:32]
Dr. Chapa
It.