Loading summary
Transcript7 lines
- [00:01]
A
This episode is brought to you by White Claw Surge. Nice choice hitting up this podcast. No surprises. You're all about diving into tastes everyone in the room can enjoy. Just like White Claw Surge. It's for celebrating those moments when connections have been made and the night's just begun. With bold flavors and 8% alcohol by volume. Unleash the night. Unleash White Claw Surge. Please drink responsibly. Hard seltzer with flavors. 8% alcohol by volume. White cloth seltzer works Chicago, Illinois. A little about me I don't really tell a lot of people this, but I was a breached birth. Yeah. You know what I'm saying? Came out of my mom's Tim's first. You heard? Yeah, kicked out that vagina like some saloon doors. I said get out of here. You hear that? I came out a breached birth. It was Tim's first meaning Timberland. And I kicked open that vagina like it was salon doors. Oh my goodness. Not a sponsor from that stand up comic. Yeah, I do like me a good breech delivery. Of course, the frequency of vaginal breaches has gone way down as that skill has kind of been lost. Although it's a good skill to have. You should know how to do a breech vaginal delivery, but most of course are by C section. But there's a better way to get out of that whole mess, which is try to vert the child so that we don't have to mess with a breech delivery in the first place. Hence the task of doing an ecv, an external cephalic version. Neuraxial analgesia. Either an epidural or a spinal combined with a tocolytic agent is the pain control method that best increases the success rate for ECV. And that's according to ACOG's practice bulletin. 2, 2, 1. Okay, so neuraxial anesthesia of some flavor. Although most people do an epidural and we'll talk about that after the intro versus a spinal combined with a tocolytic agent seems to be the way to go. However. However, some patients may be reluctant to have something in their back. A little pokey pokey in their spine. I get that. And so they may ask about IV sedation or IV analgesia. Well, there's a brand new study in agog, which is of course the gray journal that just got released ahead of print on March 5, 2026 that gives us some insights that may be helpful for patient information and patient consultation. So these investigators compared the success of ECV modes of delivery, maternal pain and complications with three different strategies. So follow this. Okay. The first strategy was IV analgesia with Remy. That's remifentanil. Some people like it, some people don't. I think remifentanyl is fantastic as a pca. We'll talk about that. Even though remifentanyl scares some people with the appropriate PNP policy and procedures. Super safe. And I'm giving you that data. But there is a disconnect with Remy that we have to discuss. Okay. Because it has to do with an FDA label and a little warning that doesn't really fit clinical usage. Nonetheless, I'll discuss that in a minute. So, anyway, so these authors out of Espana. Okay. Did you hear my lisp there? Espana? My father was Spanish, so I can do that. Was intravenous analgesia with remifentanil or the success with an epidural anesthetic or a stepwise approach. Meaning first they tried IV Remy, and if it failed, then they'd have the patient come back, like, in two days, and then they would try after an epidural. So the point is this. What is the best for analgesia, for an ecv? And that's what these Spanish investigators tried to figure out. So we're gonna get into it. I think it's very timely. You breach presentation at 36 weeks is something that. That's not unusual. And if the patient gets offered an ECV and accepts it, then we need to be able to consult her, give her some information about what is best in terms of success as well as pain. Where we're going to go here, we're going to talk about briefly, the respite trial that came out some time ago in 2018 as a Lancet. We'll talk about ACOG's practice bulletin and of course, this new publication from the gray journal from Espana. Go get some tapas with them, Espana. All right, I'm done. All right, we'll be right back after the intro. This is Dr. Chapa's obgyn no spin podcast.
- [05:05]
B
Score more with the college branded Venmo debit card and earn up to 5% cash back with Venmo stash. Got paid back with the Venmo debit card. You can instantly access your balance and spend on what you want, like game day, snacks, gear, tickets, and more. The more you do, the more cash back you can earn. Plus, there's no monthly fee or minimum balance. Sign up now@venmo venmo.com collegecard the Venmo MasterCard is issued by the Bancorp Bank NA Select Schools available Venmo Stash terms and exclusions apply at venmo me stashterms max $100 cash back per month. This episode is brought to you by Nordstrom. Spring calls for a wardrobe refresh and Nordstrom has the best styles of the season. From dresses and denim to standout tops and accessories. Find the trends and essentials that feel right for you. Discover new arrivals from brands you love like Waif, Princess, Polly, Mango, Adidas and Free People. Plus brand free shipping and returns and freestyling appointments. Make everything so easy. Shop in stores@nordstrom.com or download the Nordstrom app.
- [06:06]
A
I have visited Madrid on various occasions. If you've never been, you really got to go. I mean, tapas galore. I mean, they like their pork, that's for darn sure. And a good Spanish red wine. I mean, it's amazing. Espana, Barcelona. You really should go check it out now before we get to that new study from Espana. So let's talk about a little reminder, just briefly, about what ACOG recommends. All right? Just briefly. Just as we recap this, because it's in the practice bulletin that we mentioned in the intro, which was 2, 2, 1. Now in that guidance it reminds us that while individual studies have shown greater success rates with regional anesthesia, there really isn't that much data to say that one is better than the other, meaning epidural or spinal. Although most people go the epidural route because if they place the spinal and then the physician gets called away or there's an emergency or whatever, you are on the clock for the spinal. Remember, one shot spinal, once that wears out, it's done. But an epidural, you can keep redosing the canister. Plus if you need to move to a C section after your attempt, the analgesia anesthesia will be more long lasting. So most people go for the LEA labor epidural anesthesia over the SAB spinal anesthetic block. But nonetheless, there's not a lot of hard data that one is better than the other. But without question, neuroaxial anesthesia plus a tocolytic agent increases success and makes the procedure much more tolerable. Okay, now that brings us to this Spanish study, the title of which is Comparative effectiveness of Intravenous Remifentanyl Epidural Anesthesia or a two step Analgesic Approach for External Cephalic version and a large prospective Single center Cohort study. End quote. So I think we need to pause here for just for a minute and discuss what REMIFENTANIL actually is because you know, fentanyl of course on the news and it should be on the news. Bad fentanyl, illegal or illicit fentanyl can kill you because it's done outside of a controlled environment. And literally micro gram amounts can be too much and if used either in the wrong context or with another agent. So fentanyl freaks people out. But remifentanyl, when used in the correct way is phenomenal, despite the FDA warning, which I'm gonna talk about in a minute. Now remifentanyl, of course has been, is already used in a lot of different labor and delivery units as part of a PCA system by name. Some people know that more as ultiva. I just comment REMI or remifentanyl. But it's so, so fast and it's very predictable in. And his metabolism is very quick, right? That's why people like it because it's up very fast action and it kind of goes away, goes away very quickly. It is ultra short acting. It is a synthetic opioid receptor agonist on the MOO receptor. And it's very, very rapid onset, short duration. But it does have the potential to cause some sedation. So this is abuse both intrapartum, intraoperative. Sorry, I lost my word there. Intraoperative or postpartum for pain control in the appropriate setting. Very, very potent. But the good news is that it's metabolized very quickly by plasma esterases, not by the liver. So it's got a lot of room for metabolism. That's why it's usually done by a pca, because it goes up quick and then it goes away very, very fast. Which would be fitting of course for an ecv because an ECV doesn't take forever, right? So over about, you know, a couple of minutes, you push a little bit of remifentanyl, which is micrograms per kilo per minute. And it really does work. Now there's different protocols. Some use anywhere as low as 0.1 micrograms per kilo per minute, some use 0.5, some use 1 milligram per kilo per minute, like a small little bolus. So whatever your hospital does, stick with that. As long as you have a proper protocol, anesthesia is aware and you maintain ot. These patients should have nasal cannula to keep their oxygenation up. And of course they need a pulse ox. All right, now remember, we're just on the reminder of what REMI is. REMI is only used for IV and it's slow IV push or on a pca. It's never used as a regional. It's not used as an epidural or through intrathecal routes. It is only meant to be peripheral as an IV push or through a PCA. Okay? And you've got to adhere to your PMPs and tell anesthesia about it. Some units, it's all written for and controlled by anesthesia. Sometimes the nursing staff does it by with pharmacy. Nonetheless, just be know what you're doing because it can cause the biggest issue, of course, is respiratory depression. Now, now, here's the catch. Even though we know this works, and I'm going to give you the data here, not just from this study, but multitude of ultra of other studies that say that remifentanil used correctly absolutely is effective and much more effective than other opioid options intrapartum, and it can help reduce a patient's need for epidural. I'm going to give you those studies in a minute. However, however, you guys got to listen to this. The FDA label for Remy is kind of scary. It's like, don't use, don't use intrapartum. And it's a big narcotic. And it passes to the baby. Yes, it can. Yes, it can cause respiratory depression in the child, especially if it's proximal to delivery, just like morphine can. That' not anything unique to remifentanyl. And plus, that's why we have Narcan. But it freaks people out because there is that FDA kind of warning, just like misoprostol had the warning, you know, against using pregnant women. And obviously that's a very effective agent for cervical ripening and labor induction. All right, My point is that sometimes there's a disconnect between clinical utility and FDA label, and those are two different things. Okay? So in this case, in this case, there's plenty, plenty of data that shows that there is clinical adoption and it's growing for intrapartum because it really does work astoundingly well for pain control. Well, I was going to do this later, but let's just do this now because since we're talking about its effectiveness and we'll get into the study from Spain. Okay, first of all, the respite trial. Okay, so R E S P I T E. The respite trial, this was back in 2018 in the Lancet. This was big, big, big multicenter. It was randomized, but it wasn't thousands of women. It had like 400 women, but nonetheless very well designed. The respite Trial showed that remifentanyl as a PCA or a patient controlled analgesia absolutely was effective in reducing the need for epidural rescue or a need to switch to another agent for intrapartum pain control. It worked. Women who received remifentanyl also experience fewer instrumental vaginal deliveries compared to like an epidural, which is very good because anytime that we can prevent, you know, potential baby morbidity with a vacuum or forcep and of course protect the pelvic floor, then that's a win. So the respite trial from The Lancet in 2018 said, look man, remifentanyl, I get it, it's a little scary because it's fentanyl, it can give you some respiratory depression. But just like fentanyl is used in the or, you can use that in a labor and delivery suite intrapartum with the appropriate safeguards. All right, plus guys, plus. In 2017, so just a year before the Lancet, there had already been a Cochrane systematic review of like 20 trials that had like 3500 women that found that remifentanyl PCA was in fact superior to other parenteller opioids with a relative risk of need for rescue of like 0.5. In other words, 50% of those who had remifentanil didn't need anything else. Right. Didn't have to escalate, didn't have to switch. That's really impressive. So we got the Cochrane review from 2017, we've got the respite trial in 2018 and nonetheless the FDA warning is like you do you doctors, nurses, midwives and the rest. But we're gonna stick with the label just to be careful. And I get that that's manufacturer protecting themselves, but there is absolute clinical utility and for Remy for pain control intrapartum. Now remember guys, our objective here is not to justify remifentanyl intrapartum as, as a pain control agent is about remifentanil for an ecv, which is what we are talking about in this episode. Pain control methods that is going to increase success. So you can flip that kid so he doesn't have to kick out the vagina, the labia, like saloon doors, like our comedian said in the intro. All right, so that's the end of our little mini review. Which brings us back now of course to the AJOG new publication from 3-5-2026 out of where, guys, where? Espana. So these authors did this single center, it was consecutive three phase cohort study and it included close to 2,000 singleton pregnancies who are undergoing an external cephalic version. So let's stop there for a minute. What is going on with Spain, man? I mean, how many breech babies are they finding in a. In a time frame? Amazing. This was between. Really? What was the years here? Yeah, it looks like it was between 2020 and 2024. Okay, so, I mean, it took four years, but, man, that's still a lot. I mean, 2,000 singleton pregnancies were undergoing external cephalic version. Amazing. So short of it is it was group one, which was IV Fentanyl. There was group two, which was IV remifentanil, followed by epidural if the first attempt failed. And then Group 3, of course, were just those undergoing epidural analgesia, and they were trying to see which one worked better. All right, so these are the different time frames. Actually, the 2020 to 2024, that was group three, but group one started 2012 to 2015. So there you go. I mean, you talk about dedication, man. I mean, I guess people hang around here for a while because they started recruiting in 2012. Let me give you these ears, because I see it now in the draft, group one was 2012 to 2015. That was IV remifentanil. That was three years. Then they went 2016 to 2019. That's another three year chunk. That was group two, which was the stepwise right if IV Remy failed and went to epidural. And then the final group was from 2020 to 2024, which was the epidural cohort. Remember, three consecutive phase cohort study. That's how they got close to 2,000 singleton pregnancies in each of the three groups. Amazing. Y' all. Did y' all get this from 2012 to 2024. That is 12 years. Y' all added some dedication. It's like, hey, buddy, how's your. How's your research going? Eight more years to go, Bob. I mean, can you imagine? Hey, how's it going now? Six more years to go, and then two more years. My goodness, the Spanish are just built differently. I mean, kudos to this. This team. Three consecutive phase cohorts from 2012 ending in 2024. Mamma Mia. Wow. I guess drinking some red wine gives you a lot of patience. I don't know. All right, let's get back to this. All procedures followed a standardized protocol. They all were done by experienced obstetricians or supervised by them. In other words, maybe they had the learner. But an attending who knew what they were doing, they all had an anesthesiologist assigned to the patient. Ridadrine was used for topolysis. Notice. That's how you know it's outside of the US because we use terbutaline. And here's the catch. If Ridadrine was not available, they used Atosaban. That's how you know it's not the US because we don't have Atosaban. Atosaban is a uterine muscle relaxer, which is a oxytocin blocker. Okay? We don't have that. So that's how you know what. If you're just reading this and don't pay attention to where it's from, you're like, what? Atosa band. We had that here. No, that's why this was outside of the U.S. short of it is they had those three consecutive buckets, and they want to see very quickly which one worked better. Let's just stop beating around the bush. Epidural wins, epidural wins. Success rates were highest with the epidural at about 70% compared with IV remifentanil or the stepwise progressive approach. Now, here's the catch. If there's a higher chance of version at 70% with the epidural group, then that was also reflected, you would think, in the vaginal delivery rate. And that's exactly what they found. Maternal pain was also much better controlled with the epidural, with 78% of women reporting no or minimal pain, Whereas it was 49% in the REMI group. Okay, so once again, the epidural seems to do its job both for pain control and for success of the version. However. However, the epidural did have more episodes of maternal hypotension with associated dizziness. However, quote, neither was associated with significant obstetric clinical consequences, end quote. So you got to tell the patient, look, we get an epidural, we got the best chance for pain control, best chance to flip that kid, best chance also to relax your muscles, your abdominal muscles. But, you know, we risk a little bit of maternal hypertension. However, based on the studies, the chance that it actually, you know, causes a big issue that makes you get a stat C section is very small. Now, stat C sections are done after a version, but that's usually because prolonged vagal episodes on the child because of manipulation and. Or abruption, which can happen, but thankfully, that's very, very rare. Okay, so in this Spanish study that took 12 years to do, y', all, 12 years to do epidural was their best way to go. So they concluded, and it's also an agreement with acog. Quote in this large cohort, epidural anesthesia for external cephalic version achieved higher success, higher rates of vaginal delivery and better pain control than intravenous remifentanil.
- [20:50]
B
End quote Eczema is unpredictable, but you can flare less with ebglis, a once monthly treatment for moderate to severe eczema after an initial four month or longer dosing phase. About four in ten people taking mglis achieved itch relief in 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.
- [21:10]
C
MGLIS Lebricizumab LBKZ a 250mg per 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 ebglis. 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 Eglis before starting ebglis, tell your doctor if you have a parasitic infection.
- [21:44]
B
Ask your doctor about eglis and visit eglislily.com or call 1-800-LilyRx or 1-800-545-5979.
- [21:51]
A
Now we're getting ready to wrap this up, but I just wanted I can't let you leave the episode. We can't conclude this thinking this is the only one. It is not. There are There's a variety of published data that shows that an epidural is the bomb for ecv. So way to go. Epidural seems to win over IV sedation, it seems to win over inhalational anesthesia, and it seems to win over a variety of different IM narcotic options. This was actually looked at in a network meta analysis that compared various agents and various techniques that was published in Anesthesia and analgesia in 2020 and QUOTE Neuraxial anesthesia has significantly higher odds of successful version with an odds ratio of 2.59 compared to IV sedation, which had an odds ratio of 2. Or inhalational analgesia like Nitronox which had an odds ratio of 2.3, end quote. So they all did something, guys. But the one that seems to do the best seems to be neuraxial anesthesia. Okay? So once again, you know, we are always trying to tell you what's hot and fresh off the press, and that's clinically useful. It is not unusual that we have a candidate that's found to be breached at 36 weeks. We then offer them an ECV, and if they qualify and desire, we give them this informed consent. We say, look, we have good rates of success. We want to make you comfortable, we want to give you an epidural. We're going to give you a little shot called terbutaline. We'll do that about, about five minutes before we actually start. It works very quickly and we're going to give it the old college try as we check intermittently the baby's heartbeat and presentation with an ultrasound between attempts. And we're going to give it a shot. We're going to give it a try. Okay, so this is reassuring that ACOG's practice bulletin, which was 2, 21 on external cephalic version, seems to be supported by the data. And again, this is brand new from March of 2026. Nothing wrong with offering a patient IV remifentanyl or some other kind of IV narcotic. You can do that whatever the patient wants as long as she has informed consent that she's happy with. That's good. But if we're really trying to get the best success and the best pain control in accordance with ACOG's guidance that says that epidural analgesia and a tocolytic, you know, definitely something that can be considered here to increase the success rate of this option. Okay, so podcast family, again, we're trying to do this much more targeted. This was a brand new publication coming out in March of 2026 from SP, targeting three different approaches to pain control and success of external cephalic version and podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. And now that we've done all that, let's take it home. This is Dr. Chapma's ob gyn no spin podcast, sam.