TOLAC, PIT, and Internals: The Latest

Uterine rupture or dehiscence associated with TOLAC results in the most significant increase in the likelihood of additional maternal and neonatal morbidity. It should be noted that the terms “uterine rupture” and “uterine dehiscence” are not consistently distinguished from each other in the literature and often are used interchangeably. Furthermore, the reported incidence of uterine rupture varies in part because some studies have grouped true, catastrophic uterine rupture together with asymptomatic scar dehiscence. In January 2026, a new meta-analysis examines the relationship between oxytocin use with TOLAC and uterine rupture. In this episode, we will summarize the key findings in that study and review the data on the use of internal monitors during TOLAC. Do internal monitors (FSE, IUPC) offer a safer TOLAC compared with external monitors? Listen in for details.1. Nicolì, Pierpaolo et al.Oxytocin dosing during trial of labor after cesarean to minimize the risk of uterine rupture: a systematic review and meta-analysisAmerican Journal of Obstetrics & Gynecology MFM, Volume 8, Issue 1, 1018462. Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery. Obstetrics & Gynecology 130(5):p e217-e233, November 2017. | DOI: 10.1097/AOG.00000000000023983. ACOG Clinical Practice Guideline No. 10:Intrapartum Fetal Heart Rate Monitoring: Interpretation and Management. Obstetrics & Gynecology 146(4):p 583-599, October 2025. | DOI: 10.1097/AOG.00000000000060494. Bruno AM, Allshouse AA, Metz TD. Maximum Oxytocin Dose and Uterine Rupture During Trial of Labor After Cesarean. Obstet Gynecol. 2025 Dec 1;146(6):843-850. doi: 10.1097/AOG.0000000000006106. Epub 2025 Oct 30. PMID: 41325062.

Currently, as of today’s date, neither the ACOG nor SMFM currently support routine early induction of labor for suspected fetal macrosomia, instead recommending individualized counseling and reserving elective cesarean for extreme estimated fetal weights. However, a 2025 multicenter, open-label, randomized controlled trial was published in the Lancet comparing induction of labor versus standard care in pregnant women with fetuses suspected to be large for gestational age. The study used a parallel-group design with 1:1 randomization, enrolling women from 106 NHS hospitals across England, Scotland, and Wales. The per-protocol analysis demonstrated a significant reduction (40%) in shoulder dystocia with induction of labor at 38- 38 weeks and 4 days. Is this in conflict with the ACOG current guidance? In this episode, we will review the “Big Baby study” from the Lancet and provide 3 main limitations of this very large study, review the importance of PP vs ITT results, and explain why more data is still needed. Listen in for details. 1. ACOG PB 178; 2017 (reaffirmed 2024)2. Gardosi J, Ewington LJ, Booth K, Bick D, Bouliotis G, Butler E, Deshpande S, Ellson H, Fisher J, Gornall A, Lall R, Mistry H, Naghdi S, Petrou S, Slowther AM, Wood S, Underwood M, Quenby S. Induction of labour versus standard care to prevent shoulder dystocia in fetuses suspected to be large for gestational age in the UK (the Big Baby trial): a multicentre, open-label, randomised controlled trial. Lancet. 2025 May 17;405(10491):1743-1756. doi: 10.1016/S0140-6736(25)00162-X. Epub 2025 May 1. PMID: 40319899.3. Blaauwgeers, Anne N et al. Rethinking induction of labour for LGA fetuses: the Big Baby trial. The Lancet, Volume 406, Issue 10512, 1562

In mid-December 2025, the FDA approved an at home devicethat aims to treat depression by sending electric current into a part of the brain (the prefrontal cortex) known to regulate mood. This has been available in the UK since 2019 but it is new to the US. The manufacturer has stated that over 55,000 patients have used the device across Europe, the UK, Switzerland, and Hong Kong. How does this work? Is there data to support this new therapy? In this episode, we will summarize three consecutive years of data (2023, 2024,2025) to answer that question. Listen in for details. 1.     Sci Amer: https://www.scientificamerican.com/article/u-s-approves-first-device-to-treat-depression-with-brain-stimulation-at-home/2.     August 12, 2023: Burkhardt, Gerrit et al.Transcranial direct current stimulation as an additional treatment to selectiveserotonin reuptake inhibitors in adults with major depressive disorder inGermany (DepressionDC): a triple-blind, randomised, sham-controlled,multicentre trial The Lancet, Volume 402, Issue 10401, 545 – 5543.     October 21, 2024: Woodham, R.D., Selvaraj, S.,Lajmi, N. et al. Home-based transcranial direct current stimulation treatmentfor major depressive disorder: a fully remote phase 2 randomizedsham-controlled trial. Nat Med 31, 87–95 (2025). https://doi.org/10.1038/s41591-024-4.     December 15, 2025: Moshfeghinia R, Bordbar S,Roointanpour Y, Arab Bafrani M, Shalbafan M. Efficacy and safety of home-basedtranscranial direct current stimulation (tDCS) on patients with depressivedisorders: a systematic review and meta-analysis of randomized clinical trials.Sci Rep. 2025 Dec 15;15(1):43850. doi: 10.1038/s41598-025-28648-5. PMID:41398008; PMCID: PMC12705823.

While endometriosis is highly associated with Chronic Pelvic Pian (CPP), some women may suffer from a different primary or coexistent secondary etiology: pelvic vascular congestion, called vascular origin (VO)- CPP. Although controversial as an entity, there have been diagnostic algorithms published (via pelvic ultrasound. MRI, or venography) for this condition. Approximately 10-40% of chronic pelvic pain cases may be attributed to pelvic vascular congestion (now termed pelvic venous disorder), though estimates vary considerably depending on the population studied and diagnostic criteria used. In premenopausal women specifically, the prevalence appears higher. One study found that 8% of all premenopausal women had documented chronic pelvic pain of unclear etiology along with dilated ovarian and pelvic veins on cross-sectional imaging. Therapies for this have been limited. Flavonoids are abundant in a colorful diet of fruits, vegetables, tea, and wine, with common sources including citrus fruits (flavanones), berries, apples, grapes (flavan-3-ols/anthocyanins), onions, kale, broccoli (flavonols), and tea, cocoa, red wine (flavan-3-ols), plus soybeans (isoflavones), all providing antioxidants and potential health benefits like better heart and brain health. On Dec. 23, 2025, in the journal Phlebology, researchers published a systematic review on the potential benefits of specific flavonoid mixtures which may provide relief to VO-CPP. Listen in for insights and details.1. Gloviczki ML, Demetres MR, Salazar G, Khilnani NM. Venoactive drugs for venous origin chronic pelvic pain in women: A systematic review. Phlebology. 2025 Dec 23:2683555251411027. doi: 10.1177/02683555251411027. Epub ahead of print. PMID: 41432346.2. Knuttinen MG, Machan L, Khilnani NM, Louie M, Caridi TM, Gupta R, Winokur RS. Diagnosis and Management of Pelvic Venous Disorders: AJR Expert Panel Narrative Review. AJR Am J Roentgenol. 2023 Nov;221(5):565-574. doi: 10.2214/AJR.22.28796. Epub 2023 Apr 5. PMID: 37095667.

A brief THANK YOU prior to 2025 end.

In 2002, the National Institute of Child Health and Human Development (NICHD) proposed the 3-Tier fetal heart rate (FHR) classification system that was subsequently adopted by many organizations, categorizing tracings into three groups: Category I (normal), Category II (indeterminate), and Category III (abnormal). Recently, our podcast team received an interesting question form one of our podcast family members: “If there is a change in the fetal heart rate tracing intrapartum, but it is still in the normal range (like 120 going to 150)- and variability is normal, is that an abnormality? And what is meant by a ‘ZigZag’ FHT pattern (different than marked variability)?”. That is a fantastically complex question…and we will explain the answer in this episode.1. Zullo F, Di Mascio D, Raghuraman N, Wagner S, Brunelli R, Giancotti A, Mendez-Figueroa H, Cahill AG, Gupta M, Berghella V, Blackwell SC, Chauhan SP. Three-tiered fetal heart rate interpretation system and adverse neonatal and maternal outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol. 2023 Oct;229(4):377-387. doi: 10.1016/j.ajog.2023.04.008. Epub 2023 Apr 11. PMID: 37044237.2. Ghi T, Di Pasquo E, Dall'Asta A, et al. Intrapartum Fetal Heart Rate Between 150 and 160 BPM at or After 40 Weeks and Labor Outcome.Acta Obstetricia Et Gynecologica Scandinavica. 2021;100(3):548-554. doi:10.1111/aogs.14024.3. The 3 Tier System: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://ncc-efm.org/filz/NICHD_Reference_from_CCPR.pdf4. Jia YJ, Ghi T, Pereira S, Gracia Perez-Bonfils A, Chandraharan E. Pathophysiological Interpretation of Fetal Heart Rate Tracings in Clinical Practice. American Journal of Obstetrics and Gynecology. 2023;228(6):622-644. doi:10.1016/j.ajog.2022.05.0235. Ghi T, Di Pasquo E, Dall'Asta A, et al. Intrapartum Fetal Heart Rate Between 150 and 160 BPM at or After 40 Weeks and Labor Outcome. Acta Obstetricia Et Gynecologica Scandinavica. 2021;100(3):548-554. doi:10.1111/aogs.14024.6. Yang M, Stout MJ, López JD, Colvin R, Macones GA, Cahill AG. Association of Fetal Heart Rate Baseline Change and Neonatal Outcomes. Am J Perinatol. 2017 Jul;34(9):879-886. doi: 10.1055/s-0037-1600911. Epub 2017 Mar 16. PMID: 28301895.

Podcast Family, in our immediate past episode we tackled the discrepancy that is often found between a clinical diagnosis of intra-amniotic infection/chorioamnionitis and histological chorioamnionitis. From that episode, we received a fantastic question from one of our podcast family members: Can a patient have IAI without fever? That question is really deep and highlights a gap in the current diagnostic scheme/ criteria from the ACOG. Listen in for details!1. ACOG CO 7122. Sukumaran S, Pereira V, Mallur S, Chandraharan E. Cardiotocograph (CTG) Changes and Maternal and Neonatal Outcomes in Chorioamnionitis and/­or Funisitis Confirmed on Histopathology. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2021. C3. Romero R, Chaemsaithong P, Korzeniewski SJ, et al. Clinical Chorioamnionitis at Term III: How Well Do Clinical Criteria Perform in the Identification of Proven Intra-Amniotic Infection? Journal of Perinatal Medicine. 2015.

Welcome to "Labor & Delivery Debrief," the podcast where we tackle your toughest questions about childbirth and maternal health. Today, we're diving deep into a fascinating and critical topic sent in by one of our listeners, Sarah. Sarah asks: "Is it possible for a clinical diagnosis of chorioamnionitis to not be confirmed by placental histology? And if so, how is that possible?" This is a fantastic question that touches on the complexities of intrapartum clinical diagnosis of intraamniotic infection (IAI), also commonly known as chorioamnionitis. We'll explore the nuances of clinical versus histological findings, the diagnostic criteria, and why these two assessments don't always perfectly align. Get ready for a detailed discussion that will shed light on this important aspect of obstetric care.1. ACOG CO 712; 2017 (2025)2. Romero R, Pacora P, Kusanovic JP, et al. Clinical Chorioamnionitis at Term X: Microbiology, Clinical Signs, Placental Pathology, and Neonatal Bacteremia - Implications for Clinical Care. Journal of Perinatal Medicine. 2021;49(3):275-298. doi:10.1515/jpm-2020-0297.3. Jung E, Romero R, Suksai M, et al. Clinical Chorioamnionitis at Term: Definition, Pathogenesis, Microbiology, Diagnosis, and Treatment. AJOG. 2024;230(3S):S807-S840. doi:10.1016/j.ajog.2023.02.002.4. Oh KJ, Kim SM, Hong JS, et al. Twenty-Four Percent of Patients With Clinical Chorioamnionitis in Preterm Gestations Have No Evidence Of either Culture-Proven Intraamniotic Infection Or intraamniotic Inflammation. AJOG. 2017;216(6):604.e1-604.e11.

Depo-Provera was approved in 1992 by U.S. regulators. About 1 in 4 sexually active women in the United States have used the shot at some point, according to the U.S. Centers for Disease Control and Prevention (CDC). Meningiomas are common intracranial tumors with a female predominance. In fact, they are the most common primary brain tumor in women, with an incidence of approximately 12.76 per 100,000 in the general female population. The vast majority of these tumors are benign (World Health Organization [WHO] grade 1) while 15% to 20% of these tumors can behave atypically (WHO grade 2) and rarely, in 1% to 2% of cases, these tumors can be malignant (WHO grade 3). We covered the relationship between Depo-Provera, as a contraceptive agent, and brain meningiomas back in March 2024. With the increase in data, the ACOG released a patient centered counseling tool titled, “Counseling Patients on Birth Control Injection and Meningioma”. The most recent update on this story comes from the FDA, which has granted a medication label change to Depo-Provera (Pfizer) warning of this association. Even though association does not prove causation, the association between depo and meningiomas seems strong (with new data from the US). Does this warning extend to other progestins? Listen in for details. 1. https://podcasts.apple.com/us/podcast/dr-chapas-obgyn-clinical-pearls/id1412385746?i=10006508795722. ACOG’s “Counseling Patients on Birth Control Injection and Meningioma” 3. https://www.statnews.com/pharmalot/2025/12/17/fda-pfizer-contraception-cancer-preemption-depoprovera/4. Xiao T, Kumar P, Lobbous M, et al. Depot Medroxyprogesterone Acetate and Risk of Meningioma in the US. JAMA Neurology. 2025;82(11):1094-1102. doi:10.1001/jamaneurol.2025.3011.5. de Dios E, Näslund O, Choudhry M, et al.Prevalence and Symptoms of Incidental Meningiomas: A Population-Based Study.Acta Neurochirurgica. 2025;167(1):98. doi:10.1007/s00701-025-06506-7.6. Schaff LR, Mellinghoff IK.Glioblastoma and Other Primary Brain Malignancies in Adults: A Review. JAMA. 2023;329(7):574-587. doi:10.1001/jama.2023.0023.7. BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2023-078078 (Published 27 March 2024) Cite this as: BMJ 2024;384:e078078

The second stage of labor, characterized by active pushing and the descent of the fetal head, can be a challenging and prolonged phase for both mother and baby. Various interventions have been explored to optimize this stage, and one such technique involves the application of vaginal lubricants. The rationale behind this approach is to reduce friction between the fetal head and the birth canal, potentially leading to smoother and faster delivery. Does this seemingly simple technique work? Does the ACOG mention this in the CPG 8 from January 2024? What does the latest research tell us about its effectiveness in assisting or speeding up the birthing process? Listen in for details.1. Yang Q, Cao X, Hu S, Sun M, Lai H, Hou L, Wang Q, Wu C, Wu Y, Xiao L, Luo X, Tian J, Ge L, Shi L. Lubricant for reducing perineal trauma: A systematic review and meta-analysis of randomized controlled trials. J Obstet Gynaecol Res. 2022 Nov;48(11):2807-2820. doi: 10.1111/jog.15399. Epub 2022 Aug 16. PMID: 36319196.2. ACOG: First and Second Stage Labor Management Clinical Practice Guideline Number 8: January 20243. Aquino CI, Saccone G, Troisi J, Zullo F, Guida M, Berghella V. Use of lubricant gel to shorten the second stage of labor during vaginal delivery. J Matern Fetal Neonatal Med. 2019 Dec;32(24):4166-4173. doi: 10.1080/14767058.2018.1482271. Epub 2018 Jun 27. PMID: 29804505.4. Beckmann MM, Stock OM. Antenatal Perineal Massage for Reducing Perineal Trauma. The Cochrane Database of Systematic Reviews. 2013;(4):CD005123. doi:10.1002/14651858.CD005123.pub3.