Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 11.7 Professional Guideline Discrepancies on Labor And Delivery
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We talk with Dr. Emily Donelan about how conflicting labor management guidelines can derail communication between nurses and physicians and quietly raise patient safety risks. We map the biggest friction points and lay out practical ways to reconcile guidance locally while pushing for a unified national approach.
• defining “communication dystocia” and why guideline discrepancies create real bedside conflict
• how evidence gaps drive teams toward institutional culture and inertia in practice
• the ARRIVE trial as a case study in differing priorities and framing
• a detailed induction vignette showing where amniotomy, oxytocin titration and uterine activity definitions collide
• why the 20 mU/min oxytocin threshold persists and what newer data suggests
• tachysystole rules, Category II tracings and how prescriptive language shapes nursing behavior
• delayed pushing versus pushing at complete dilation and the moral distress it can create
• the need for standardized evidence grading and cleaner citations across organizations
• a national interprofessional reconciliation program and who must be at the table
• one actionable step for tomorrow: stay curious and surface the real reason behind the disagreement
Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram.
0:01 Why Guideline Conflicts Matter
3:52 The ARRIVE Trial Framing Problem
12:23 A Labor Case Where Rules Collide
24:08 Oxytocin Thresholds And Litigation Fear
33:26 Pushing Timing And Moral Distress
38:05 Who Should Write Unified Guidance
44:04 Evidence Grading And Bedside Decisions
52:05 Inertia In Practice And De-Implementation
1:00:14 Takeaways Plus A No-Evidence Pet Peeve
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Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Emily Dunilan discussing conflicting labor management guidelines.
SPEAKER_02Emily?
SPEAKER_01What are we thinking about on today's podcast?
SPEAKER_02Well, we're talking about your new article in the March 2026 Green Journal. For our listeners, allow me to introduce Dr. Emily Donalin. Dr. Donalin is an obstetrician gynecologist at Dartmouth Hitchcock Medical Center and a faculty member at the Geisel, is that right, School of Medicine? At Dartmouth. So she's the lead author of a really great new article in the March Green Journal titled Professional Guideline Discrepancies as a Barrier to Labor Progress and Teamwork. So her article sheds light on really a critical but often overlooked challenge in labor and delivery, which is how conflicting guidelines from our major professional organizations, and in this case ACOG and A1, although it could be the anesthesia folks, it could be a lot of other people we interface with, but how these can create what she calls a communication dystocia and potentially compromise patient safety. So Emily, welcome to the show.
SPEAKER_01Thanks, Howard. I'm really excited to be here today.
SPEAKER_02By the way, Antonia loves this phrase, communication dystopia.
SPEAKER_01Guideline Discord is a barrier to labor progress and teamwork. But I guess the editors didn't appreciate my brand of humor.
The ARRIVE Trial Framing Problem
SPEAKER_02Aaron Powell Well, that's okay. So well, let me hopefully, and we mentioned this on the last episode to tease it. So hopefully a lot of people have already read the article before hearing this episode. If not, pause it, go read it. But let me give you the takeaways from the article. So there is this, as you call it, this communication dystotia where in particular discrepancies between the American College of Obstration and Gynecologists and the Association of Women's Health, Substetric Indian AL Nurses, or ACOG and A1, can lead to team conflict and potential safety risks when those guidelines are in conflict. And then that's in this background of a huge vacuum of evidence. So it's true, and we talk about that a lot on here, there is an absence of high-quality evidence around a lot of things we do in labor and delivery. So then teams often will default to their local institutional culture, their personal experience, just the way we've done things, the way I was trained, things like that. And that can be difficult to change. And maybe if we have time, we'll talk about some of that I call it inertia in practice. And then the ever-present, every OBGYN in the country has dealt with this oxytocin tension. So it seems like there's this persistent conflict regarding oxytocin dosing. How much, how soon, all that. So A1 emphasizes in its writings this idea of the lowest amount of oxytocin. And really you're getting angsty when it's any time you're talking about something over 20 milliunits per minute. But ACOG says no maximum dose has been established, no maximum safe dose has been established, maybe with the exception of VBAC. In that literature, there's a little bit more data there about VBAC, but for non-scarred uteruses. And then pushing protocols. ACOG recommends that we should start pushing at complete dilation, and A1 suggests delaying pushing until the mother feels the urge to push. So here we are with conflicting guidelines, which you emphasize, and what's a potential solution. And you've proposed a national interprofessional program of to reconcile these disparate guidelines and bridge the gaps and then restore trust within our teams and even just with patients who sometimes hear the physician steps out of the room and the nurse has one thing and the physician comes back in and that's not good for anybody. So you've coined this term bestosia of communication. Can you explain what that looks like on a busy labor unit?
SPEAKER_01Yeah. So I've worked on several labor and delivery units in my career, and I've always been struck by the fact that it sometimes feels like I'm speaking a different language than the nurses. We would sometimes step out the room out of the room if there was a conflict about oxytocin titration or artificial rupture of membranes or management. And they would start using terminology like uterine resting tone and relaxation time. And I was always very focused on tachycystole and MVUs. And I could tell that we were all trying to accomplish the same goal, which of course is a vaginal birth with a good maternal and neonatal outcome. But conversation often stalled when we tried to discuss how to practically accomplish this goal, of course, especially when it came to discussions about oxytocin titration, as you mentioned earlier.
SPEAKER_02Right. And your article mentions that nearly 47%, I think was a number of clinicians have seen patients at risk due to these communication failures. So how much of this is interpersonal? How much of this is structural? What's going on here?
SPEAKER_01I think it's a combination of both. There's, of course, a common stereotype that labor and delivery nurses and obstetricians are strong-willed and opinionated, which can naturally noticed. Oh, yeah. I I definitely am. I don't know about you, Howard, but I am, which can naturally lead to interpersonal conflict. But I believe the issue goes further than that. And really it goes beyond just personality differences and clashes. And in our article, we referenced two studies, one from 2011, the other from 2014, both by Audrey Lyndon, who interestingly also authored the Awon textbook, Fetal Monitoring, Principles and Practices. And her two articles highlight that provider nurse conflict has been a long-standing issue in obstetrics. And I really appreciate that she is bringing that to light in the literature and paying attention to a problem that most of us experience daily. But I think that there's too much emphasis in those articles on interpersonal dynamics. And what's often overlooked are the structural factors contributing to this tension, most notably the misalignment between ACOG and AWAN, like we've been discussing. And these inconsistencies can create confusion and put providers and nurses in really difficult positions and ultimately setting teams up for conflict despite shared goals for patient care.
SPEAKER_02Okay, so why do two professional organizations looking at the same body of evidence, as it were, why do they come to such different conclusions?
SPEAKER_01I think it's similar to why many professional organizations arrive at different conclusions, such as about breast cancer screening guidelines, for one, which we're all, I think, well aware of. And part of it comes down to perspective: who's making the recommendation, what is their background, their priorities, their incentives. I think people also naturally assign different value to different outcomes, which influences how they might interpret the same body of evidence. One example along these lines that I find particularly interesting is how the arrive trial is framed differently by ACOG and AWAN, despite, of course, relying on the exact same body of evidence, which is the primary article. And ACOG's statement is that patients, quote, should receive counseling regarding the potential benefits and risks of induction of labor at or beyond 39 weeks of gestation compared with expectant management. And to me, this feels like a balanced and fair interpretation. And it aligns with the conclusions drawn by the study authors themselves. And the risks and benefits of a 39-week induction can vary widely depending on the context, such as that hospital's cesarean rate for induced patients, which can vary widely across the country, as well as that individual patient's values and whether they really want to avoid hypertensive disease because their sister had pre-eclampsia and they watched her go through that. Or maybe the opposite. But in contrast, A1's interpretation of the arrived trial states, quote, results of a recent rigorously designed multi-center randomized clinical trial arrive, confirm that it is safe for the healthy woman and fetus to await spontaneous labor. It then goes on to caution that, quote, there is a potential for an increase in elective induction and a concomitant escalation of the medicalization of childbirth. And what I think is so striking about these two statements is that they seem internally inconsistent. So if expectant management is affirmed to be safe, it's unclear why that alone would then justify concerns about an increased medicalization of childbirth. And more importantly, this framing doesn't really reflect the study's outcomes, which demonstrated a lower cesarean delivery, at least in that patient population, as well as hypertensive disorders in the induction group with no difference in neonatal outcomes. And I think as you and Antonia highlight so well on this podcast, medical literature is incredibly nuanced. And to counsel patients effectively, we really have to understand that study in minute detail. And just as importantly, then be able to translate that evidence into the context for that individual sitting in front of us and how that's relevant to that patient.
SPEAKER_02Yeah. There's a world in which you can take those two comments that you mentioned about the arrived trial, and they're both true in a sense. So that so neither group misled or said something different. But as you said, they started from different priorities. Yep. And if and from A1's perspective, if nobody should get oxytocin, for example, and that's what they mean by increased medicalization of pregnancy, well, obviously your people will get oxytocin.
SPEAKER_01Absolutely.
SPEAKER_02Things like that. So they're both true statements, but priorities are different. And I do think that's useful when you're dealing with patients, obviously, and what are their goals and priorities. And our job is to help bridge the gap between that. And so, yeah, we look at the same stuff. I also think as a separate, as an aside, the quality of literature that one might accept as proof positive that a certain intervention is helpful, or our philosophical perspective about what is good. So I was thinking, for example, CHG washes three days before cesarean to reduce the rate of infection. Well, there is no good RTC that says that that works. There are some trials that says that there's no difference. But then there's microbiological data that says that there's lower colonization counts on the skin flora, but then that hasn't translated into lower surgical site infections, et cetera. So one person may say, yeah, what's the harm? There is some data. Maybe on the fringe it helps people. And then I think, if anything, I'm known for being the harsh skeptic that's like, yes, but it doesn't result in fewer SSIs and whatever. And so both statements are true. And your perspective and your starting point matters. And also that's why culture's so pervasive, because if you're culturally have been doing that, well, you're not going to stop doing it just because an RTC didn't find a difference in infection rates. You're you're the inertia of practice is likely to continue. It's your cultural preset.
SPEAKER_01But you might not start, right? You might not start doing a practice like that. And then you have a new doc who comes in from a hospital that didn't do that practice and now feels like this is a non-evidence-based intervention. And I think these conflicts come up in so many different areas. It's not just ACOG and A1 and it's a broader issue.
SPEAKER_02Yeah. I've worked at a bunch of different hospitals too. And currently I work at two different ones, and they're they're not far apart, but the cultures are so different. Do you labor with the Foley if you have an epidural versus not? And so many of those are the same things.
SPEAKER_01Oh yes, that's a hot topic.
SPEAKER_02Both hospitals have good outcomes and like it's fine. And of course, that's why we have a lack of robust evidence, is because the truth is you can do it a lot of different ways and have pretty good outcomes. And we don't know all of the vital elements. We know a lot and we do those, hopefully, but a lot of the details and the nuance is absent in the robust literature.
SPEAKER_01Aaron Powell Any trial that's going to be able to find a difference is going to have to have an inordinate number of patients, right? Because even think about that Foley example. UTIs are almost unheard of. We our CODI rate is so low that we could never power a trial to see the difference between a foley versus intermittent straight catheterization. So yeah.
A Labor Case Where Rules Collide
SPEAKER_02And then your philosophical perspective matters, because I'm of the philosophical tilt that if you can't prove to me that it helps, don't do it. And remember the lessons of DES or things like that. And other people are of the philosophical tilt. Well, but maybe there's someone that that helped, and what's the harm? And there's where we find on this podcast. So you start out with this great vignette, which I assume is a true story, although that's a composite of many true stories. I was wondering because it's courageous to actually put in a real life because I didn't want your the actual nurse involved in the thing reading that and and all that. No. You described this 38-year-old patient where the nurse and obstetrician were not on the same page, and you show several examples. So what was the turning point in that scenario? And you can remind us of it a little bit if you want to, but what was the turning point in that scenario where the guidelines collided? You set this up so we would see this impact.
SPEAKER_01Yeah. So I'm happy to read the scenario or just go through the perfect. All right. So I think most people can probably identify with a patient very similar to this one. She is a 38-year-old G1P0 who was admitted for an induction of labor for preeclampsia at 37 weeks and five days. Her labor was initiated with the cervical ripening balloon and mesoprostal. On toco, she had low amplitude, painless contractions, and her nurse expressed concern about the risk of inducing tachycy due to the use of mesoprostal along with the cervical ripening balloon. After her balloon was expelled, the oxytocin was initiated and the obstetrician recommended artificial rupture of membranes. Her nurse requested a delay in the A-ROM. After six more hours in latent labor on oxytocin, the obstetrician performed the A-ROM and the patient progressed to active phase. Despite oxytocin at 22 mU per minute, she remained at 7 centimeters for four hours with an intrauterine pressure catheter in place and had inadequate contractions, fewer than 200 MVUs. The nurse did not increase her oxytocin during that time given the intermittent variable decelerations in the setting of a normal baseline and moderate variability. The fetal heart rate eventually improved to category one with intrauterine resuscitation. Her nurse turned down her oxytocin because of uterine resting tone that was elevated at 35 millimeters of mercury. Two hours later, the patient had no cervical change and a cesarean delivery was performed for arrested dilation and active labor. The team performed a debrief, and all participants expressed frustration with the labor management, especially around communication and the clinical outcome. The patient had hoped for a vaginal birth, and the next day on rounds, she reflected that the team did not seem to be on the same page during her labor. So, from this example, you can see we tried to add several different areas of tension in that scenario that reflect the most common conflicts that we assert see occur between providers and nurses. And the first area of conflict in that scenario is really over the choice of cervical ripening agents. So in the ACOG documents, they encourage the use of dual ripening with mesoprostal and a foley balloon. Well, Awon actually makes zero mention of combination methods in their documents. Additionally, the nurse in the scenario expresses concern about the patient's painless, low amplitude contractions, which is a reference to an Awon statement about mesoprostal that says, quote, consider delaying or avoiding administration in a woman with frequent low amplitude, painless contractions or two or more painful contractions per 10 minutes, particularly if a uterotonic has already been administered. This statement has no reference attached to it and really has the potential to delay mesoprostal dosing and unnecessarily prolonged cervical ripening. And I can personally say in my practice, I have had this happen to me many times.
SPEAKER_02Yeah, it's very frustrating. And I was thinking too about how we develop defensive measures, like depending on some of these conflicts you're going to talk about, we put in the fewer IEPCs so they can't measure the resting tone, or we we don't use mesoprostal with cervical folies, depending on who the nurse is, because we're worried that the oxytocin won't get started eventually or things like that. And we shouldn't have to do that.
SPEAKER_01Yeah, yeah. I think it's a really great point. And I think we all know that it happens. And then in the next area of conflict between the physician and the nurse in this scenario is about artificial rupture of membranes. The provider wants to perform an early ARAM, but the nurse requests a delay. And that is probably because ACOG and their clinical practice guideline number eight encourages early amniotomy, which they define as within one hour of Foley removal to reduce the length of induction. And that's a very evidence-based intervention that has a lot of data behind it. A1 does not discuss amniotomy as a tool for labor induction, but rather solely in the context of protracted labor, which I think can cause a lot of confusion for nursing when they're taking care of a patient who is not in spontaneous labor rather than being induced. They see this tool as something to help if labor is not progressing rather than a prophylactic intervention that actually improves outcomes.
SPEAKER_02Yeah. And we do have several high-quality studies now that show that early A-ROM is beneficial for both augmented labor and induced labor. And that has gone back and forth over the years. The other thing I'm seeing in some of these conflicts is just timing and when you last reviewed the literature. But culturally, if you're also avoiding interventions, of course, you're going to emphasize cord prolapse, you're going to emphasize time of AROM and infection risk. And in I think in the units that have the most breakdown, there's also this idea that the nurses are protecting the patient from the doctor who's going to section them unnecessarily. And I do like in your vignette, let's establish the common goal. I want my patients to have safe vaginal deliveries. My nurse wants my patients to have safe vaginal deliveries. Let's get on the same page.
SPEAKER_01Exactly. So the next conflict in the scenario is around oxytocin titration in the setting of a category two tracing. And most providers that I know are very comfortable increasing oxytocin in this scenario that I described, where the patient has a normal baseline, moderate variability, and just intermittent variable decelerations. But I think the conflict comes in when the nurses are interpreting some of the A1 teachings very literally. And they may not titrate oxytocin in the setting of a category two tracing at all, even one that is relatively reassuring, like I described. And there is a quote in the A1 monograph that says the fetal heart rate should be normal before proceeding with oxytocin. And that's a really nebulous statement. I'm not sure what normal means. Does that mean category one? But I think that some people interpret that it that way and won't titrate oxytocin in the setting of a category two.
SPEAKER_02Which is also interesting in a world, of course, we had uh adopted the same nomenclature prior to the creation of the category or the tiers, but but they've adopted that too. And we don't use terms like normal anymore. Although if you were going to use it, I would interpret category three as abnormal. And I would interpret because it's indeterminate, I guess, if you want to say normal, indeterminate, and abnormal, but indeterminate it's not abnormal. So it's really powerful if you say normal versus abnormal. And don't start oxytocin with an abnormal category three tracing. Sure.
SPEAKER_01I think we can all agree we shouldn't do that.
SPEAKER_02What percentage of women in labor have category two tracings? Most 80%. Yeah.
SPEAKER_01So the final conflict in this scenario is about uterine resting tone. And the nurse in the scenario turns down the oxytocin despite inadequate MVUs because the patient's resting tone is 35. And this is a reference to the fact that ACOG and A1 have different definitions of normal uterine activity. ACOG defines tachycystole as the only parameter that has a meaningful impact on neonatal outcomes. And A1 defines several other characteristics of excessive uterine activity, including contractions that last two minutes or longer, insufficient return of the uterine resting tone between contractions via palpation, or intraamniotic pressure above 25 millimeters of mercury between contractions via an IEPC, as well as normal relaxation time, which they define as 60 seconds in the first stage and 45 seconds in the second stage between contractions. And I think we can all agree that of course there should be time between contractions and that the uterus should relax between contractions. That of course makes physiologic sense and is important for placental blood flow. Unfortunately, Awon has defined incredibly specific criteria for what is normal based on very low quality evidence. And this can often lead to nurses focusing on one parameter without being able to see the bigger picture. And this is actually very common, I would say, in patients who are of a higher BMI and often that IUPC is reading high, even though that's probably not a proper reflection of their true resting tone. And if you actually palpate their uterus, you can sometimes feel that they get hard and they get soft. But we're sometimes really stuck on looking at these IUPC readings. And I think that really sometimes can impact patient care in a negative way.
SPEAKER_02And those parameters that you mentioned specifically, those are not based on even low quality evidence really. They're they come from descriptive, if you go back to the 1960s, they come from descriptive studies of what people in labor typically look like. And but they're not based upon data that reflects harm if they're if you're it's obviously a range of how this works. I also always think about with IEPC data and MVUs, when you get 200 MVUs, that's described and and that number came from that was clinically adequate for about 90% of women to progress in labor, but it wasn't for 10%. And that data comes from the 1970s, I think, before the obesity epidemic. And so yeah, we have a lot of concerns about the accuracy of those readings and how much oxytocin an obese perituant might need compared to a non-obese patient, things like that. So we need things based upon robust data, particularly when there's an implication of harm associated with it. And that should be easy to establish from literature, but none of those parameters you mentioned, to my knowledge, are based upon data that shows that being on the wrong side of those thresholds is associated with harm. So yeah.
SPEAKER_01And interestingly, my nurses and I were able to find figure out where the A1 reference comes from for the 45 seconds and 60 seconds. And it comes from a 2007 article by Baker and all. And it was a retrospective study looking at neonatal outcomes. And they basically took babies with a cord pH greater than 7.11 and babies with a cord pH of less than 7.11 and looked at uterine contraction parameters, just like you were mentioning, what is quote normal. And in the group that had a higher cord pH, the average contraction or distance between contractions in the first stage of labor was about 60 seconds. And in the second stage it was about 45. They actually round it, I can't remember the exact values. But that that is, I believe, where A1 gets that information, which is again helpful, interesting. I think we can always use that as a guideline. And many oxytocin titration orders in the computer will have that as guidelines to help the nurses. But I think it's really when we get really fixated on like exactly this many seconds and this is vital for patient care that we really get stuck.
SPEAKER_02And if you're thinking about tachycystole, you've essentially captured the essence of that anyway because if you're going to have if if you're only going to have five or fewer contractions in a 10 minute period, you're going to be in those. So that's the other question is picking up on those all this individual parameters, is it better than just being conscientious about tachystystole? So that's a great point. So at your institution you use the labor unit you said as a laboratory for communication improvement. So what'd you learn when you had nurses and providers, you have physicians and midwives residents read each other's guidelines, maybe for the first time.
Oxytocin Thresholds And Litigation Fear
SPEAKER_01Yeah, it's really interesting. So I stepped into the role of medical director in 2024 and immediately identified a need for more multidisciplinary learning and collaboration, especially around protocols and evidence-based labor management. And I was really fortunate to work with an excellent nursing director, Caitlin Yeazel, who played a key role in helping me to bring nurses and providers together. And we established multidisciplinary work groups that focused on we had a workflow work group, a communication one. And then most relevant to this article was our evidence-based labor management work group. And one of the first things that our labor management group did was to review the ACOG and A1 guidelines side by side. And it was super eye-opening for everybody involved, including me. I had never before this read all of the A1 documents. And I think it really gave us perspective on where each other was coming from and depersonalized a lot of the conflict. But it's not about me and this nurse. It's about what I learned and my teaching as a physician and what she learned in her AWN classes. And I think it helped us to understand the conflict better and really help us find common ground. So I would encourage any groups that are struggling to take a similar approach.
SPEAKER_02Okay. So one of the things that you talk about in the vignette and that we all have encountered everywhere is this idea about maximum dose of oxytocin. And there's a lot of directions this goes high dose protocols versus low dose protocols, how quickly you start it. I think a lot of people in practice don't even realize some of the I won't say crazy, but some of the really higher dose protocols that have been used in the past like San Antonio pit where you just geometric doubling and you get to very high levels of oxytocin very quickly. But commonly very commonly there is a threshold of don't go above 20 milliunits per minute of oxytocin. That's a stopping point even though in the same breath MVUs of 200 is a goal and or things like that. But 20 units is in a lot of pre-standing orders it's in a lot of hospital protocols and it feels like you're doing something bad half the time when you're you have to ask permission to go above 20. And let's say not for VBAC that's a totally different conversation and there is some literature around there. It's not great but there's some literature around there. But for normal labors, particularly for obese women going above 20 is in my view well supported by the evidence. It's a key to lowering the cesarean rate, the disparate cesarean rate in obese patients. So what's going on with this 20 milliunit threshold?
SPEAKER_01Yeah my sense is that the concern around going above 20 probably originated from the A1 documents and then made its way into many like you mentioned hospital protocols and order sets and got embedded into practice. And A1 includes language in their practice monograph that says quote a bedside evaluation by a physician or certified nurse midwife is needed to increase beyond 20 milliunits per minute. And this should only be considered in unusual clinical situations, which again sounds very scary, right? You read that as a new nurse and you come onto the floor and a provider is asking you to go above 20 and I understand now why that makes them feel anxious and why they feel uncomfortable about that. But as you mentioned it's not based on good evidence, right? And so in 2023 Mo and Sun and colleagues published a secondary analysis of a randomized controlled trial comparing high dose versus standard dose oxytocin. And this was a well-designed study conducted at a large US center. It was actually at Northwestern and I was there at the time. And fun fact, I was a participant I wouldn't let my OBGIN start my oxytocin until I signed that consent form and enrolled myself in the trial. So anyways what was most interesting about this trial actually is that it was blinded and it was really well blinded. So the pharmacy would mix up the bags of oxytocin and send them down and nobody knew what concentration was in them. So when the nurse was titrating the pit, she was on the pump going up by quote two, but if the patient was in the high dose protocol, she was actually going up by six and she was completely blind to that process. And so in the original trial the higher dose oxytocin did not increase cesarean rates, but it did shorten labor and was associated with a lower rate of chorioamionitis without worsening neonatal outcomes. And then in her secondary analysis she was specifically looking at whether that 20 units matters, right? Is this threshold is it justified that we kind of panic about it? And what they found was no significant increase in adverse maternal or neonatal outcomes above or below that 20. And interestingly if you look at the appendix for that paper and you look at how high they were able to get the highest study participant got to a pitocin of 90 milliunits per minute which I think if any nurse had seen that on a pump probably would have had a heart attack. But because it was blinded, we got there.
SPEAKER_02Yeah. And I also think that a lot of this as you said it's interesting nursing and administration I think are usually in most hospital settings more integrated and work together and administration uses nursing to work on quality projects and things like that. And providers are sometimes not integrated into the system completely. And so I do think that it has just found its way in there through because nursing has had influence on development of these protocols and then A1's influence that but also risk management and risk management they have their own literature and their own literature talks about med mal cases involving obstetrics and the most cited complaint and because it's basically cited in virtually every obstetric scale you're going to make a list of we we claiming this happened and this happened. Oxytocin is number one most cited complaint. So the risk management is like we need to have very specific safe protocols around oxytocin and they have pushed this Uber conservatism as well. But then ironically that is increasing the risk to patients particularly again take somebody with a BMI of 60 yeah they might need 40 or more milliunits per minute of oxytocin and so we're just increasing the risk of cesarean. So there's a difference between it being cited by plaintiff's attorneys and actually being a cause of harm and that we need to remind folks of that.
SPEAKER_01Yeah and I do think I feel bad for our nursing colleagues because some of them go to these A1 conferences and these other nursing conferences and there's a lot of presentations about litigation and they will sometimes come back with even more litigation fear than they started out with. And as you mentioned it's almost always around oxytocin titration and this fear that they're going to do something wrong and that's going to put them and their patient at risk.
SPEAKER_02Yeah. Okay A1 also suggests treating tachystystole even for a category one tracing. So no even potential adverse fetal response to the tachycystole. ACOG is grayer it's at least less prescriptive and I do I see that you may not have that much of that issue at your facility but I see in different places I've worked where we're carefully counting those contractions and the second we hit five we have to do something. We have to turn the oxytocin down we have to we can't stay the course even though the baby is like category one beautiful reactive. And so that's another area of tension or at least I won't go up on it. So your oxytocin's been on eight for nine hours and we're four centimeters. And the only reason why we're not going up on it is because there are five contractions in ten minutes. And I think physiologically going up on the pitocin is not going to make six contractions in ten minutes. It's going to make those contractions that you have stronger but I do see that as an area where oxytocin is used less I don't want to even say aggressively because that makes it sound bad. It's even the way we talk about it, right? Maybe use less appropriately at higher doses for patients who need it. And so that that's another conflict and you were mentioning that's not so much of a problem at your facility but I bet for a lot of listeners they see a lot of struggle over that.
SPEAKER_01Yeah we don't see this as much but I think one thing that you mentioned that we do see that I think is just a good reminder is that tachycystole should be the average over 30 minutes. And so I think there's sometimes this we see five contractions oh we have to immediately turn down the oxytocin and that's actually not true right we can wait for that 30 minutes and then average those contractions over 30 minutes before we jump to that conclusion. So we do have to remind our nursing staff of that sometimes.
SPEAKER_02And you can do things like turn the patient on her side that actually will reduce that tachystole usually and the problem goes away. So right yeah.
unknownOkay.
SPEAKER_01Yeah. And the the A1 new intermediate class does recommend that if there are no signs of fetal hypoxia that you would turn the patient, give them a fluid bolus, but then if it doesn't improve in 10 to 15 minutes they do recommend halfing the oxytocin, which is a pretty big drop in oxytocin.
Pushing Timing And Moral Distress
SPEAKER_02That's a big change. Yeah. Particularly for a patient who you know who has no issues with it. No we need more research there, but we're well, you talk in the article about how we manage adverse adverse is not even the right word, category two tracings, indeterminate tracings, how we manage those and there isn't clear recommendation really from either professional organization. A1 is probably a little bit more prescriptive about it, but these are indeterminate tracings. We don't know that these are a cause of harm. We do know that cesarean is a cause of harm. So it's a conflict. Another conflict that you talk about of course is when to initiate pushing and we've gone through this labor down laboring down phase over the years. We've we didn't have a lot of robust data. We've had several trials ACOG now is not recommending laboring down in most contexts. You could have a patient with a cardiac lesion or a neurologic lesion or there's a there's uses for it. For sure. Yeah.
SPEAKER_01But how does this specific disagreement sometimes create moral distress for the teen yeah so this again is not something that I see have seen in my practice very much but I have talked to colleagues across the country who have said this is a real point of tension. And like you mentioned I certainly throughout my residency we labored patients down all the time. But in 2018 there was a large multi-center randomized control trial in the US that looked at noliparous patients with noraxial anesthesia and compared immediate versus delayed pushing. And what they found was really important there was no difference in spontaneous vaginal delivery rates, but delayed pushing significantly prolonged the second stage and more concerning the trial was stopped early because of an increased risk in the delayed pushing group things like postpartum hemorrhage, chorioaminitis and neonatal acidemia. And based on that evidence, as you mentioned ACOG does recommend pushing at complete dilation for the majority of patients there's certainly circumstances where it would be appropriate. And A1 does support delayed pushing in their documents and they suggest waiting until the patient feels the urge to push sometimes up to one to two hours depending on parity and framing that as a way to potentially support fetal well-being, which again is in direct conflict with what that 2018 paper mentioned. And I think the moral distress is real. If you're a bedside nurse and you're trying to do the right thing and you've read all of the ACOG guidelines and they're suggesting that you should wait till the patient has an urge to push and then you have a provider come in and say, she's 10, it's time, let's get going, I imagine that feels terrible for that nurse and certainly again is either going to lead to her just saying yes and feeling really bad inside or maybe leading to her telling the patient, no, don't we're not going to push or maybe in hospitals where nurses are doing the exams, it potentially could even say lead to a nurse calling her nine and not 10 because she's trying to avoid the physician from coming in and starting pushing. So I can see how this would cause moral distress all around.
SPEAKER_02Yeah. And that goes both ways. You said read the ACAR guidelines, which you meant read the A1 guidelines, but on the other hand your physician who reads the ACAR guidelines and in in that 2018 study is concerned about potential harm. And then of course the patient's caught in the middle sometimes particularly if these are these ideas are expressed openly and it becomes a competition or a conflict and we never want that. We don't want we want these discussions to be private and and based in evidence and grounded in common goals and not in front of the patient. I also wonder when I think about things like that how much of this how much of both of our sides if you want to call it sides, we should be on the same team here, but how much of it's rooted in misinformation on social media? There's a lot about delayed pushing and French women never push. That's all over OB TikTok now.
SPEAKER_01Breathe your baby out.
SPEAKER_02Yeah breathe your baby out and a lot of that information is totally misrepresented. There's this it shortens labor seven minutes, but it lengthens the second stage automatically by an hour or two hours or whatever you're adopting. And it's an interesting thing. But well and there are other conflicts we could talk about the difference I'm working in my institution trying to change our internal protocols about oxygen administration since over the summer ACOG has taken a more directive stance against oxygen. A1 of course still supports it so we're working through those issues are you still using oxygen as a resuscitative measure? I haven't in years but some of the facilities some of the facilities do because it's in our protocols which are older and of course the problem with updating the protocols is that A1 still says you might consider using it, right? And so then it's this very conflict you're talking about where we have to get together and we're going to do it and we're this is functions well. But it does create this conflict where nursing support will say well A1 says it still works and ACOG says it doesn't and then who wins? And of course that has a tendency perhaps to promote a physician hierarchy that is people are less comfortable with today. If I just walk in there and say well I'm the doctor do it our nurses are outstanding professionals who have their own scientific organizations and their own body of literature. So we need to reconcile these things to avoid these conflicts. So and you talk about that a program for reconciliation. So who needs to be at the table ACOG A1 obviously who else?
SPEAKER_01Yeah I think if we really want to address this conflict it has to be everybody who's involved in labor management which as you mentioned ACOG A1 SMFM ACNM the AAFP along with the people who are actually at the bedside and I think this is where sometimes breakdown happens is we need bedside nurses, we need physicians, we need midwives and we need patience because when we're having these conversations I think we need everybody sitting in a room who again all wants that best outcome for that patient to help make some of these decisions and reconcile these differences. And right now many of these groups are developing recommendations in parallel and even when everyone shares that same goal, the guidance doesn't align. And again this is what's causing that conflict. So I think if we could bring these voices together, it would give guidance guide it would give guideline authors a much clearer understanding of where the friction actually is, which recommendations are creating confusion, where are teams interpreting things differently, where is the evidence thin, evolving or simply absent? And that last piece is really important because it's not just about aligning what we already know, it's also an opportunity to create a shared research agenda. If multiple organizations can agree on where the biggest gaps in knowledge exist, they can help prioritize and support the studies that would actually answer the questions that clinicians are struggling with at the bedside. And that kind of collaboration could move us toward a more aligned transparent guidance while also accelerating the generation of better evidence. Because ultimately this isn't just about reducing conflict. It's about building a shared understanding strengthening interpersonal interdisciplinary collaboration and making sure the care we provide is grounded in both the best available evidence and the realities of clinical practice.
SPEAKER_02Yeah I was just thinking it would be wonderful if we actually had a co-authored guideline around these areas. Why do we even have two guidelines? And why can't ACOG and A1 and other partners SMFM, AAFP, whoever get together and co-author a guideline and have really a shared front on all this information. That would probably go a long way to helping this situation. The other thing you talk about is how evidence is graded differently by the different organizations and you cite a few examples where you know ACOG in its out in its documents will cite and grade the evidence and the A1 just often puts a citation without thinking about the quality or the grading of the evidence. So how would a standardized grading of evidence help a busy bedside nurse or resident make better decisions? And why why haven't we done this?
SPEAKER_01Yeah I think it makes a huge difference because I think you know at least for me when I read an ACOG document and I see something that says strong recommendation, high quality evidence, I'm going to try to implement that consistently and when I see something that says weak recommendation, low quality evidence or expert opinion, I think it's still interesting and is something I may use in my practice, but is certainly not something that I feel like needs to consistently happen every time. And I think it just helps you put it in context for when you're then dealing with a patient. And I think a great example of this is in the Awon textbook, Fetal Heart Monitoring Principles and Practices, AWON recommends temporarily discontinuing pushing or reducing pushing to every other or every third contraction when the fetal heart rate is indeterminate or abnormal with the goal of improving fetal status. But when you look at the reference behind that recommendation, it's based on a trial of 45 patients that was actually designed to compare immediate versus delayed pushing. And the study mentions limiting pushing frequency as part of its protocol for both groups, but it doesn't report data on how often that strategy was used or whether it improved neonatal outcomes. And importantly there isn't additional supporting evidence cited for this practice elsewhere in any of their materials, nor is it clearly acknowledged that is a limitation. In contrast, ACOG includes modifying pushing efforts as a potential resuscitative strategy in one of their new documents, but they explicitly state that this recommendation is based on expert opinion rather than high quality evidence. And I think that this distinction really does matter because when you're at the bedside and a nurse maybe suggests, how about we push every other and if both of those people in the room had contacts for this being a possible thing that may help, but not necessarily based in high quality evidence, I think then when it either doesn't work or if the physician says I actually think a couple more pushes and we're going to have a baby. So maybe we shouldn't be holding off on pushes, I think it would hopefully allow both parties to see that's okay. We don't have to follow that as a guideline. That's just a suggestion.
Evidence Grading And Bedside Decisions
SPEAKER_02Yeah that's the importance of knowing what's low quality is both, as you said, how dogmatic do I get about this? Where do we need more research? If you've if you're aware of a low quality recommendation and then next summer a new study comes out that addresses that maybe points it more one direction or the other, you're not surprised. This isn't something you became dogmatically attached to because you thought this was super good all the time. And in those low quality recommendations or expert opinion recommendations, they're often very scenario specific. I might want to continue pushing right now because I want the baby low enough to grab with forceps or vacuum and I'm thinking about I've got five minutes to grab this baby or I'm doing a cesarean and the nurse is thinking I should take the next two contractions off. Well you just killed my five minutes. So there's different context but maybe she has a dense epidural and everything's okay and we want to change positions and take time. So understanding the grading and quality of evidence is incredibly important to how you implement those sorts of things. But okay well if a listener is currently experiencing some of this friction Friction on their unit. And we both should say right now that we both have wonderful labor and delivery nurses, and none of this is about them.
SPEAKER_01100%.
SPEAKER_02If one of our listeners is currently experiencing this friction, what's one local thing, a step positive step that they can do tomorrow when they go to work to start to close this gap?
SPEAKER_01Yeah. I think my advice to providers and nurses, I mean anybody listening, is just get curious about the conflict. Because the more that we can really step back and genuinely have curiosity about why this conflict is happening, the more we're going to be able to get to the root of the cause and have productive conversation and move forward. Because I may think that a nurse is not titrating oxytocin for some reason. And her reason may be completely different. And if I don't understand that reason, I really can't address it. And so I would say just keep an open mind, get curious, and try to get on the same page about what's going on before moving forward with that discussion. I should also add, I appreciate all my co-author nurses for helping me stay curious during this process of paper writing. I had many co-authors on this paper, but I appreciate my nursing colleagues for reminding me that curiosity gets us the answers.
SPEAKER_02Okay, another thing that I hadn't remembered if I had ever read it was, and you talked about was the epidurals and the potential increased risks of it. So in there, A1 misquoted they cite as a reference the ACOG practice bulletin, and they but they misquoted or they misunderstand it perhaps. So ACOG describes epidural and spinal analgesia as having minimal maternal and anatol adverse effects. That's a quote. But A1 really highlights the risks of complications such as hypotension, which they say is in approximately 10% of women with low dose neuraxial A ranalgesia, fever in approximately 30% of women with neuraxial Arianalgesia, generally unrelated infection, but causing diagnostic confusion. I read that one and I thought, really? A third of women have fevers? Because I can't remember. Are they not telling me that they're getting fevers? That was just like a drawdrop moment for me because it's so disconnected from reality. And then they say in fetal heart rate decelerations and bradycardia in 17 to 42% of women. And that boy, that that seems like the upfront bias is anti-epidural.
unknownYeah.
SPEAKER_02You're taking this and interpreting it in the most negative way you possibly could.
SPEAKER_01Yeah, and I think I agree with you. And I think if you read the Awon information on analges or epidural or neuraxial analgesia, it definitely has a an anti-bias to it. And I think the statement that you just read, one of the biggest issues is that Awon is actually citing an ACOG practice bulletin with when they make that statement, the one obstetric analgesia and anesthesia, as a source for the rate of the fetal heart rate changes that they mentioned. However, the rate of 17 to 42% is actually the rate of elevated uterine resting tone after epidural or CSC, respectively, and not representative of fetal heart rate changes with noraxial. So it's a it's a complete misquote. And the original study quoted in the ACOG practice bulletin actually found that 31% of patients experience fetal heart rate changes, defined as prolonged decelerations or bradycardia after a combined spinal epidural, but only 5.6% of the epidural-only group experience the same changes. And this is indicative of a common issue in medicine and rampant in some of the A1 documents is making comments without citations or citations that don't actually say what the text says. There's also several examples of kind of this these circular citations where the authors will quote each other. So, you know, the monograph will quote the textbook or the textbook will quote the monograph, and you actually can't find the primary literature anywhere.
SPEAKER_02So well, I was shocked by the 30% fever thing. And again, that that does come from the practice bulletin.
SPEAKER_01It does, yeah.
SPEAKER_02But what it says is in the practice bulletin, approximately 30% of parituents will experience an increase in maternal temperature higher than 37.5 Celsius or 99.5 Fahrenheit with neuroaxial analgesia. And they cite a study, which I did track down and to try to get to the primary sources. This was a study from 2010 by Sigal, labor epidural analgesia and maternal fever. And the key point there, I think, is the key misunderstanding is the A1 document says fever. And fever to me is 38 degrees. And the vast majority of those now we'll call it elevated temperatures were less than 38 degrees. They weren't clinical fevers. They weren't, they didn't, they wouldn't have triggered our threshold for calling them fever. So calling them fever was very inappropriate in the A1 document because it implies something that's not true. There is, I read a lot about this because I just something I didn't know. There is a whole literature about elevated temperatures with epidurals and lots of theories about it, about why it may happen, but it doesn't cause fetal tachycardia in this context. It's not associated with more fetal tachycardia, and it's not clinically useful. And the idea that it is confused with, oh, I wonder if you have choreo because you have an epidural, I think that's what's implied. You might think that by reading the A1 statement about it causing confusion. But but that's just a clear factual error because you said 30% caused fever. You cited ACOG, and ACOG did not say that. And 98 or 99.5 degrees or 37.5 degrees Celsius is not a fever.
SPEAKER_01Yeah.
SPEAKER_02I think other things that I was thinking about in regards to all this is of course a lot of this is motivated by medical malpractice issues. And so we have us maybe two standards of care that might come into play. And that's interesting to think about in in that situation. If a nurse is following A1's very conservative oxytocin titration guidelines, and a physician's following ACOG's more liberal protocols and which organization wins in court, who looks better in court, do we have a battle of experts unnecessarily over this? I will point out, and you point out, I believe, that both documents say that these should not be interpreted as standards of care.
SPEAKER_01Yes, they both have disclaimers, which I appreciate very much.
Inertia In Practice And De-Implementation
SPEAKER_02Aaron Ross Powell Yeah. But we don't want this expert witness trap where you've got a battle of experts, and the maybe this is one of the reasons why oxytocin is so cited in some of these trials, is because the oxytocin was on 26, there was an adverse outcome, and you can get an expert to come in and testify to what an A1 document might say or things like that. So I think that's an importance of a unified approach. Your article also notes that a lot of local units will default to institutional culture in an evidence vacuum, which I think is another way of saying like inertia. We're just going to keep doing what we've done and what our local standard of care is. And lawyers are sometimes interested in that too. But if a hospital's internal policy aligns with ACOG, but then a nurse is sued for not following A1 standard of care that she was taught, then that's a conflict. And how does a hospital policy give her legal safe harbor? Does it create a trap for her professional license? I think there's a lot of issues here that having that doing the work you're trying to do and unifying these policies and being on the same page will help. I also think that, again, a reminder, these are not standard-to-care documents. And if experts are using either of them in a court setting as a standard to care thing, then they're probably hurting us anyway. I'm very interested, and we don't have time to talk to talk about that today, but I'm very interested in this idea about why inertia of practice happens. And I think that there's three big areas, and you've highlighted all these in a way. So there's this the cognitive elements. So our human brains are not naturally wired to think vis-a-vis the scientific method. We're wired for stories and social cohesion. So we have the sunken cost fallacy where we've just been doing it this way for so long, and it's hard, psychologically painful to admit that maybe a better way or a different way is better or superior or cheaper or whatever. We have the confirmation bias where we all remember that one patient who benefited from an intervention that systematic evidence is saying isn't helpful. And we value anecdote over systematic evidence or some abstract p-value in a journal. And then our brains are stressed by cognitive dissonance. And it's really hard to admit that a long-standing thing we've done that we've done for years that we thought was helpful for patients might actually be useless or worse, might even be harmful. And so we tend to reject evidence that causes cognitive dissonance because it helps protect our image of ourselves as healers who are trying to help people. And of course, we socially work in an authority bias, a hierarchical system. So if the department chair does it a certain way, if the oldest nurse on the unit does it a certain way, the nurse manager does it a certain way or whatever, that seems to be more important than the latest issue of the New England Journal of Medicine or some abstract paper might say. And then the second category is I think we have these external pressures, and them it doesn't apply necessarily here, but fee for service-based medicine is an external pressure that causes us to keep doing interventions that maybe we shouldn't. But another external pressure is one we were just talking about, defensive medicine. So we want to do everything we can to make the chart look as good as possible to avoid litigation. And ironically, we sometimes end up harming the patient in our efforts to not go above 20 milliunits of per minute of oxytocin, the patient got a cesarean or things like that. I think even for artificial rupture of membranes, we don't want to be the ones to rupture the membrane and have the cord prolapse. But in reality, if you're doing a controlled rupture of membranes and you have somebody applying pressure and you're doing it right, you actually may mitigate or minimize the risk of cord prolapse by taking that polyhydramniose patient and doing it under a controlled circumstance and making sure we're ready to respond rather than at eight centimeters, it does it on its own. So we sometimes have to take a risk to prevent a risk.
SPEAKER_01Yeah, Howard, I love that example because I talk to my residents all the time about cord prolapse with A-ROM. And I think you have one cord prolapse and nobody wants to A-ROM anybody for the rest of the month. And I think you talk about it in your book, which is, and correct me because I don't know the correct term, but it's like the action bias versus inaction bias. What is it?
SPEAKER_02Tendency to action versus inaction, yeah.
SPEAKER_01Yeah. And I think there is this fear around if I don't do, if I don't touch the patient or I don't do anything, it's not my fault, or that's gonna at least if there's a bad outcome, it's not my fault. But what I think we forget is actually that might not be true. Your inaction may actually be worsening this patient outcome if you don't break her bag, if you don't start her oxytocin, if you don't titrate it appropriately. And I think that bias is very common on the labor floor.
SPEAKER_02Yeah. Well, and then the third, these are we'll do a whole episode on this sometime. And you're welcome to come back and do this. Or I've been thinking about this episode, but there's also these structural and cultural forces, these invisible rules that guide how we think about stuff in the medical ecosystem and that tends us to maintain the status quo and preserve what we've been doing. So there's this the hidden curriculum. Medical schools try to teach evidence-based medicine, but the reality of it is the hidden curriculum is what students see all the time, and the same for nursing students and nurses. So if you're culturally anti-epidural or you're culturally anti-oxytocin, then there's this idea of we don't do what the book says, we do what works, we do what we do, that sort of thing. But that hidden curriculum is much more powerful than what we write in articles or in texts.
SPEAKER_01I think it's a good reminder too. I obviously am very involved in policy work. And you can change a policy, you can rewrite a policy, but that doesn't change your culture. And that is not going to actually change how people behave on the floor unless you get to some of these deep-seated beliefs about oxytocin and these other things. So I think it's a great point that it's not what's in the book or the article or even your policy. It's what people are doing practically on the floor.
SPEAKER_02Right. So take the oxy, the oxygen issue that we were talking about. So we're working in my institution to get these old out-of-date policies changed. But then beyond that, there is what I call the complexity of de-implementation. So okay, we've we've done it this way for years. We ran into the room and put the non-rebreather on our mouth, on our face because the there was fetal distress on all this stuff. And we've done this for all this time. And now they just you just change a policy up and uh abstractly, and people aren't going to stop doing that. So this complexity of de-implementation is a real thing. And removing what has been a standard of care, whether it was right or not right, requires unlearning in in many cases for hundreds or thousands of staff and updating all of the little pathways that have really led to that. We made it so easy to have the non-rebreather sitting there, or the we've made it so easy to do it because we wanted everybody to do it, and now we've got to remove all that. We've got to remove the EHR shortcuts, we've got to change the order sets, we've got to change patient expectations who wonder why their sister had oxygen when this happened two years ago, but now they don't. And patient expectations are part of that. I'm glad that you mentioned having patients at the table for their perspectives and all that. But patients often feel that they haven't been treated unless they have been treated in a way that that folks are used to, or unless they've received something or they want something done or whatever. I think that doesn't necessarily apply to what we're talking about here, but it applies to areas like tocolytics and things like that. It's so hard to unwind the practice because patients are expecting it. They read on the internet that they should get it. You didn't treat me. And so that's just one of these many things that are a structural or cultural force that makes it hard for us to do that. But yeah, I could talk for a whole bunch of time about that.
SPEAKER_01I was gonna say, I do find that patients are very receptive when you talk about the literature and you talk about, especially historically. Like you can sometimes I'll tell patients, like, interestingly, we used to give this medicine all the time. People used to go home with pumps of tokelytics and yeah, turbulene pumps. And in what we found is that not only was that not helpful, but it was harmful. And I find that when you explain that and you explain the history and the newer evidence, I find that patients are really receptive to it. So I think involving them more will hopefully help them say, oh yeah, I actually do want the most recent evidence-based intervention and not these things that don't work or have no evidence.
SPEAKER_02So Yeah. All right. Well, so some takeaways, dystopia of communication, interprofessional conflict is not about personality clashes, hopefully. It's often has this structural route or structural failure from, and in this case, very specifically from conflicting guidelines that you're gonna work on getting changed for us.
SPEAKER_01I'm gonna try.
Takeaways Plus A No-Evidence Pet Peeve
SPEAKER_02You're gonna try. And and we need to cross-pollinate the cultural stuff. If you've worked at one labor and delivery, you've worked at one labor and delivery. And it's amazing to go work at other labor and deliveries and see that they don't do that thing at all that you thought was super important and they have similar outcomes or even better outcomes. Like cross-pollination is super important. That helps break up hierarchies and cultures and things like that, especially when you're trying to do change management. And you but you can have local reconciliation. You can your your units can reduce conflict by having working groups like you guys formed, looking at each other's guidelines, looking at the evidence, finding a shared language of how you manage patients and how you talk about differences of management options and things like that. But Okay, before we leave, I did ask you to think about a thing we do without evidence, because listeners really like those. So do you have one?
SPEAKER_01I do. How about when people put a snap on the suture at the edge of the hysterotomy when the uterus is exteriorized, only to then remove it before they put the uterus back in the abdomen and then put the snap back on.
SPEAKER_02Sure. Yeah, I've seen that. And I guess and I don't do that at all. I just cut the suture and all that. But I guess the idea was if you tag the suture, then when you have the uterus inside, you'll be able to see your edges better by referencing the suture that you've held on to. But and that's okay. I think sometimes I think that's fine. Yeah, with learners, I don't do that routinely. I look at it and it's dry and I put it in. But if you have resonance and stuff like that, you might be more worried about it. So you want to look at your edge, but do you need to take the hemostat or the snap off before you put it back in? I guess they think that it's in the way, or what's the thinking?
SPEAKER_01Well, I think the concern is that if you push the uterus back in with a snap on, you could potentially be pushing the snap into some major blood vessel, which actually Yeah, a bowel or into the broad, which I think is reasonable. But my my question always is, well, why don't you just wait to put it on until the uterus is back in then if you're gonna take it off? Um Right.
SPEAKER_02There's so many things like that. That's the cultural thing again. If you've done 100 C-sections with me, you and 100 C-sections with somebody else, 100 C sections with you, you'd see that there's all kinds of little idiosyncrasies or little cultural, local institutional things that we've done that other people don't. And by seeing that's that cross-pollination, then you see you your mind says, is this really necessary? But yeah, I'm all for minimizing steps at surgery down to the simplest and non-irreducible steps to save.
SPEAKER_01Yeah, I've heard you talk about your 12-minute C-section. I'm working on it.
SPEAKER_02All right. Well, we would love to have you back on, and uh this has been great. So you either have to write another article in the Green Journal in the next few months, or we'll have to pick another topic. That's a lot of pressure. Yeah.
SPEAKER_01Maybe another topic.
SPEAKER_02We'll pick another topic then. Okay. Well, we'll see everybody in a couple of weeks.
SPEAKER_00Awesome. Thanks, Howard. Thanks for listening. Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram. We'll be back in two weeks.