Podcasts about practice bulletin

In the ACOG Practice Bulletin 205 (Reaffirmed August 2025), the stated risk of uterine rupture with TOLAC is stated as 0.7% (after 1 prior LTCS). However, as our podcast tag list holds true, "Medicine Moves Fast". In an new upcoming publication from Obstet Gynecol (The Green Journal), May 2025, authors looked at the rate of uterine rupture with TOLAC over a 12 year interval. The rate of uterine rupture was NOT close to the national quoted rate in the Practice Bulletin. This information, which was also presented at the Jan-Feb 2025 Pregnancy Meeting, can be very helpful in counseling patients desiring TOLAC. Listen in for details.

Today we have another reprise episode in line with our new GOALS curriculum! We cover medication abortions and review Practice Bulletin 225 that came out this month. We review who is eligible for medication abortion as well as risks, benefits, and other management guidelines.  Remember to join OB GYN GOALS for further learning that lines up with today's episode: www.obgyngoals.org  Twitter: @creogsovercoff1  Instagram: @creogsovercoffee Facebook: www.facebook.com/creogsovercoffee Website: www.creogsovercoffee.com You can find the OBG Project at: www.obgproject.com

In this episode Dr. Moyers discusses: All things ovarian cysts. The timeframe that most simple ovarian cyst resolve. It's longer than you think! Also, when you need referral to a gyn oncologist for surgical intervention. 2 case studies of benign ovarian cysts that were removed surgically Sources: Variables Associated With Resolution and Persistence of Ovarian Cysts, Lasher, Anne MD, Obstetrics & Gynecology 142(6):p 1293-1301, December 2023.  Management of Adnexal Cysts. Practice Bulletin 174, Nov 2016. Ovarian Cysts FAQ **This is not medical advice, just medical education. Please ask your doctor medical questions as they pertain to your specific situation. Educational purposes only. #gynecology #ovariancysts Dr. Carolyn Moyers, DO is a board certified OBGYN and Neuromusculoskeletal Medicine physician, and founder of Sky Women's Health, a boutique practice in Fort Worth, Texas. Welcome to the Sky Women community where we are all stronger together. Sky Women's Health: Https://www.skywomenshealth.com 1125 S Henderson St, Fort Worth, TX 76104 To become a patient: email hello@skywomenshealth.com or call 817-915-9803.

Women of Strength, how many of you have “failure to progress” on your operative report as the reason for your Cesarean(s)? Meagan and Julie talk ALL about failure to progress today– how it led to their own Cesareans and how after breaking it down, they both realized that neither of them actually qualified for that label. When is it failure to progress and when is it failure to wait? What does failure to progress actually mean? This is an episode you will want to listen to over and over again. From learning all of the ways a cervix changes other than just dilation to all of the possible positions you can try during a lull in labor, Meagan and Julie share invaluable current research and personal experiences on this hot topic! ACOG Article: Limiting Interventions During Labor and BirthAJOG Article: Safe Prevention of a Primary Cesarean DeliveryThe Journal of Perinatal Education: Preventing a Primary CesareanOBG Project ArticleThe VBAC Link Blog: Failure to ProgressHow to VBAC: The Ultimate Prep Course for ParentsFull Transcript under Episode Details Meagan: Hello. I am with Julie today and we are going to be talking about failure to progress. If you have been diagnosed with failure to progress– and I say diagnosed because they actually put them on our op reports like it's a diagnosis of failure of progress meaning our cervix does not know what to do. It cannot make it to 10 centimeters or it hasn't or it will not in the future, then I am telling you right now that this is definitely a great episode for you. Even if you haven't been told, it's going to be a great episode because we are going to talk about some other great things in the end about what to do in labor position-wise and all of the things. So we're going to get going, but Julie apparently has a Review of the Week. We weren't going to do one, but she says she has a Review of the Week. So, Julie? I will turn the time over to you. Julie: This is my review. Are you ready? Meagan: I'm actually really curious. Julie: “I'm so excited. Thank you so much, Meagan and Julie. I love The VBAC Link!” Signed, lots of people everywhere. Meagan: I love it. Julie: We don't have a Review of the Week so I just made one up. Boom. There. Signed, AnonymousMeagan: All right, you guys. Failure to progress: what it is and what it isn't. Let's talk about what it is. What does it mean? Essentially, it means that your provider believes that your cervix did not progress in an adequate amount of time and there's also failure to progress as in your body may have gone into or you are going in for an induction and then they couldn't even get labor going which we all know is usually not the case that your body really couldn't do it, but failure to progress is when your cervix does not continually dilate in an adequate amount of time. Would you change anything about that, Julie, or add anything to that? Julie: Sorry, I didn't hear half of that. I was just going through it. I was going through the things just to make sure that we are 100% accurate on what we are about to say. Whatever you said, yeah. That sounds great. Yeah. Let's go with it. Meagan: Failure to progress– the cervix is not dilating in an adequate amount of time. Julie: Basically, yeah. Your cervix isn't changing so you've got to do a C-section because it's not working basically. Meagan: Okay, so what it isn't– do you want to talk about what it isn't? Julie: What it isn't? It isn't– sorry, I'm trying to say it. Meagan: It isn't true most of the time. Julie: Most of the time it's not true. It isn't what we think it is and if it is, it's not a sign that your body is broken. It's not exclusion. It's not a reason to exclude you from trying for a VBAC. It's not your fault. It usually is a failure from the system where people are in a rush or in a hurry and just not knowing how to move past a stall in labor or not understanding the true flow of how some labors take. I mean, I was diagnosed with failure to progress. You were diagnosed with failure to progress and I know that both of our literal clinical outlook at the time we were diagnosed with failure to progress was not true failure to progress. Meagan: Mhmm. Julie: According to what the actual guidelines and requirements are. So I always say, yeah. What you said, it is not true. Meagan: It is not true.Julie: We joke about that and use it loosely. Sometimes it is true. I've seen one true failure to progress diagnosis in over 100 births, but I feel like most of us listening and most of us who have C-sections have them because of failure to progress. Now, mine when I was in labor, I was not told failure to progress. I was told fetal heart tones, but that's another topic for another episode– what we are told versus what is in our op reports. So yeah, let's do a little plug-in about getting your op report. Find out what is actually in the notes that say why your C-section was called because it's not uncommon for what it was written down to be different than what you were told in the moment. I feel like having an accurate clinical understanding of what your Cesarean looks like on paper to another doctor who is reviewing your birth is super important. Meagan: Absolutely. I agree and also, I think that it's important to note that if you have been told this and you have doubt in your body, that it is normal to have doubt because we have been told that we can't do something and that our body can't dilate, but I also want to plug-in that really try not to believe that. Try your hardest. Do whatever you can to not believe that. It's going to help you. Believe the opposite. Believe that your body can do it. Believe that you were most likely set up in a less-ideal circumstance that created that result, right? Like an induction– it was a failure to descend, not progress, but I just recorded a story the other day where her water was broken at 6 centimeters, baby came down wonky. They couldn't get baby out and they diagnosed her with CPD. There are these things that are happening a lot of the time where we are walking in to be induced way too early or really any time we are being induced could be too early especially if it's just an elective. It can definitely be too early and our body is not ready so our body is not responding or our body is overwhelmed because it's been given so much so fast and it doesn't know what to do so it doesn't react the way a provider wants it to by our cervix dilating. It almost is reacting in the reverse way where it's tense and tight and like, No. I'm not ready and I'm not letting this baby out. Don't you feel like you've seen that? Julie: Yeah. We've seen lots of things. I feel like that's the tricky thing. We as doulas and birth photographers really do get to see the whole gamut of everything from home to birth center to hospital and everything. I feel like we have such a unique perspective on how labor is managed in and out of hospitals and how stalls or lulls in labor are managed in both places. Let me tell you, it's often way smoother and in my opinion way better outcomes when you are out of the hospital and that happens. Meagan: Mhmm. Labor at home as long as you can. Yeah. I mean, one of the stories that I just recorded was an accidental home birth. It was not her plan, not even close, and it will for sure come across that way when she is telling the story, but there were so many things that she did within that labor like movement from the shower to the toilet to walking down the stairs to moving back to the toilet. There was all of this movement that sometimes doesn't happen in a hospital or we've got, like I said, “Let's break your water. Let's do these things.” We've got these interventions that may help, but doesn't always. It may also cause problems. Okay, so we have some updates for you on the safe prevention of a primary Cesarean delivery that Julie has found and then we also want to talk about what is adequate labor too? What does that mean and where do we decide or where does a provider decide if labor is not adequate? Julie, do you want to talk about this for a minute on what you found from the OB/GYN Project? Julie: That's just a really nice summary. I really like it because it is all laid out really nicely. I am seeking out different pieces of information because there is updated information so I'm just looking for that. I'm not quite 100% certain I can speak to when it came out. Evidence-Based Birth has some great information. They did a podcast episode on the Friedman's curve. We know that dilating 1 centimeter an hour is based on the study that Friedman did. That's incredibly flawed but there is new updated, more evidence-based information that has come out. I'm trying to find out when it came out actually because the Friedman curve was established I think in 1956 and let's see. In the 2010's there were big shifts in the evidence. In 2014, ACOG had a study. Maternal Fetal Medicine published new guidelines on labor progress. Okay, so 2014 it looks like which is actually not that new anymore because it's 10 years later. That was, I think– I don't think it's actually shifted that much at all. I'm just trying to figure that out right now. I'm sorry. Let's see. The Practice Bulletin– yeah. You go. Safe Prevention of the Primary Cesarean Delivery. Meagan: I think we are looking at approaches to limit interventions during labor and birth, but we know that a lot of the time when we are introducing interventions, that is where we often will receive a failure to progress diagnosis because we are really introducing things, like I said earlier, when the body is not quite ready or the baby is not quite ready. Maybe the baby was already too high and was trying to make their way around and into the pelvis but now we've got an asynclitic baby or a transverse baby or an OP baby.This one, Number 766 which we will have in today's show notes actually originally replaced the committee of 687 in February 2017. The 766 was in 2019 and reaffirmed in 2021. Something that I like that it goes through is recommendations for women who are at term and spontaneous labor it happening. It talks about admission upon labor. It talks about premature rupture of membrane or rupturing of membranes which I think is a big one. Really, through my own experience but also doula experience, I've seen so many people go through membrane rupturing whether artificially or spontaneously and then nothing is happening so we go in and we get induced. Or we are told the second our water breaks that we have to go in, then labor has not started yet so we are intervening. One of the things it says is, “When membranes rupture at term before the onset of labor, approximately 77-79% of women will go into labor spontaneously within 12 hours. 95% will start labor within 24-28 hours.” I just had this experience with a VBAC client just the other day. Her water broke and within about 9 hours, she was starting to contract and within less than that, she actually progressed really quickly. Baby was born. That was really great but then there are situations like myself where it takes forever for labor to even start. It took 18 hours for my very first contraction with my second baby to even start and then by 24-28 hours, I was in a repeat C-section because my body didn't progress fast enough according to my provider.It says that, “The median time to delivery for women managed expectantly is 33 hours and 95% had delivered by 94-107 hours after rupture of membranes.” I think that is something also really important to note that if your water breaks, it doesn't mean we're just having a baby right away. It doesn't mean that our body is failing because we haven't started labor. 94-107 hours after the rupture of membranes is when the baby had been born. That's some time. We need to allow for the time. Julie: That's why I hate it when hospitals say, “If your water breaks, come in right now.” No. Meagan: I know. My provider did that too because it makes sense in our heads. They're saying, “Oh, just come in because we have to monitor baby because of infection and all of this stuff.” But we also have to take a step back and realize that once we go into that environment, one, that's a new environment. We're not familiar with that. All of those germs in that environment, we're not accustomed to. We're not immune to them. And then two, we know that the second we go into labor and delivery units, what happens? They want to check our cervix which means–Julie: Bacteria. Meagan: There is bacteria that is possibly being exposed to the vaginal canal, right? Even if it's a sterile glove, that still raises chances. Julie: Yeah, sterile gloves really are not as sterile as people think. Meagan: There are these things to keep in mind, but it's so hard because for me, I had premature rupture of membranes. My body didn't start labor, but I was told failure to progress after 12 hours for only reaching 3 centimeters. I was told failure to progress. I just really liked that. I mean, I like a whole bunch of this but I really liked that part of the rupture of membranes because I think so often we are told, “Oh, your water is broken. You're not progressing. You are a failure to progress.” Or we are not progressing so we have to break our water to try and speed our labor up and then that doesn't happen and then we are failure to progress. Can you see the problem here? Julie: Total problem. Meagan: It's a problem. Julie: It is a problem. So many problems. It's fine. I just dropped two different links to the updated guidelines because it's really funny. I've been going down the rabbit hole now while you've been talking so if I'm repeating things like I tend to do on you sometimes, please forgive me. I just think it's interesting. There is starting to be a shift in pulling away from Friedman's curve and going into a different way to consider an actual progression of labor which is a really cool, nice little shifty-shift here. I feel like maybe let's talk about what failure to progress really is. What are the guidelines for it? What is real failure to progress versus what you've probably been told about it? First of all, let's just talk about– nothing. Meagan: Can we use my own birth example just as a starting point to what this evidence is showing us or what the guidelines are? My water had broken spontaneously. It took a little bit to start labor. Within 12 hours, I was 3 centimeters and was told that my pelvis was too small and that I was failure to progress. Water broken, I was 3 centimeters 12 hours into labor. all right, Julie. What am I? Am I real, true failure to progress or not? Julie: No, you're not. Absolutely not, are you kidding me? Because you were still in the first stage of labor. That is the number one thing. According to clinical guidelines, it is not failure to progress until you're in the second stage of labor which is at least 6 centimeters dilated. So guess what, friends? If you got called failure to progress before you were 6 centimeters dilated– mine was labeled failure to progress at 4 centimeters so that rules me out. I mean, there are lots of things that rule me out and Meagan. But if you are less than 6 centimeters, it is not failure to progress. Meagan: Yeah, it even says right here. “Active phase arrest is defined as a woman at or beyond 6 centimeters dilation with ruptured of membranes who fails to progress despite 4 hours of adequate uterine activity or at least 6 hours of oxytocin administration with an adequate uterine activity and no cervical change.” Can we talk about that too? Adequate uterine activity. You guys, at 3 centimeters with my water broken, I was still not in an active pattern to progress. It takes time. Our uterus doesn't just start contracting regularly and adequately. It takes time. Then at that, I was only on oxytocin for 2 hours. Julie: Pitocin. You were on Pitocin. Meagan: Sorry. That's what I meant. Pitocin. I'm looking at the word oxytocin administration. Pitocin. Julie: We all know the truth. Meagan: We all know that Pitocin is not oxytocin. Julie: That is a soapbox for another day. Meagan: I was only on Pitocin for 2 hours. 2 hours. At the top, it says, “Slow but progressive labor in the first stage of labor should not be an indication for a Cesarean. With a few exceptions, prolonged late phase greater than 20 hours in a first-time mother and greater than 14 hours in a multi (so a mom who is not a first-time mom) should not be an indication for Cesarean as long. As the mother and the baby are doing well, cervical dilation of 6 centimeters should be the threshold of an active phase of labor.”Julie: Exactly. That's it too. Later on after this, we're going to talk about all the different ways a cervix can change because can I just tell you what? Someone says, “I'm 5 centimeters. I'm still 5 centimeters, great. Cool. What else has your cervix been doing? We're going to talk about that in just a second.” But yes, that's the thing. It's not failure to progress before 6 centimeters. It has to be 4 hours of adequate uterine activity which means strong, consistent contractions. Contractions that are strong enough. We could talk about the Montevideo units which is another measurement of the strength of contractions. We're not going to talk about that because we just don't have time, but are your uterine contractions strong enough? Yes? Then it's got to be at least 4 hours without cervical change. No? Then great. Let's do Pitocin and the inadequate amount of uterine activity. It says 6 hours or more of Pitocin without adequate uterine activity. If you've been on Pitocin for 6 hours and your contractions– which has caused that adequate contractions– and there is still no cervical change, then you are failure to progress Let's talk about cervical change though because the cervix goes through so many things. When I was doula-ing, I talked about this a lot in our second prenatal visit about how a lot of times you'll be like, Oh, cervical change. Yeah, dilation. Am I 4, 5, 6, 7, 8? But listen. The cervix goes through changes in 6 different ways. It moves forward so from posterior pointing backward toward to your spine. It straightens out to a more downward position. It softens so it goes from hard like your forehead to hard like your nose to softer like your chin. It softens. It effaces which means it thins out so it starts thick. It thins out which is effacement. It dilates obviously which is the opening and then baby's station like where baby is in the pelvis. Baby drops down, rotates, and descends. If you were 3 centimeters at your last cervical check and 60% effaced and 2 hours later at your next cervical check, you are 3 centimeters and 80% effaced, your cervix has thinned by 20% which is a good amount of cervical change. Meagan: Good change, yeah. Julie: If you were 6 centimeters and your baby was at a -2 station and at your next cervical check, you are 6 centimeters and your baby is -1 station which means your baby is lower in the pelvis, that is a cervical change. All of these things are shifting so I feel like it's important that when we are talking about failure to progress or when we are talking about labor progress that we consider all of the things the cervix does.I was just at a birth yesterday– not yesterday, two days ago. I don't know. It was all night and it was long for me. All night is long. It doesn't matter if i was there for 6 hours or 20 hours. If it was all night, I'm going to call it long as I'm getting older. The client was still 4-5 centimeters but the cervix was a lot softer or stretchier I think at the one before this. Oh yeah, your cervix is super stretchy now. Those are all great cervical changes even though the dilation number hasn't changed. Meagan: Yeah, so coming forward, thinning out, really softening up, baby dropping– all of these things are signs of progression and so it's something to keep in mind if a provider is like, “Well, you've been sitting at 6.5 centimeters now for 9 hours,” or whatever, but at the same time, your cervix went from 40% to 80% thinned and it went from super posterior to more mid-line and baby went from -3 to a 0. These are changes. These are absolutely changes and there are so many things that go into that. If a baby is high and not well-applied because they are trying to work their way down to the pelvis and our cervix is working on coming forward, there is so much that goes into that where now we're going to have a baby. If that change was made, now maybe we can have a baby that was well-applied to the cervix creating good pressure. Uterine activity is getting stronger. Things are progressing in the right way.So in the ACOG thing, it does say that in contrast to the prior suggested threshold of 4 centimeters which we know is very outdated, the onset of active labor–Julie: Right, that was according to the Friedman's curve. Friedman's curve called active labor at 4 centimeters but now we are getting all of this new information that yeah, it's probably at 6. I feel like when you and me started as doulas 9-10 years ago, it was 4 centimeters, but a couple years after that, everything started shifting into 6. So it's actually not that new, but kind of new. Sorry, keep going. Meagan: Yeah. I want to get into our positions really quickly, but it does say even in here, the onset of labor for many women may not occur until 5-6 centimeters. May not occur until then and then we know that sometimes around 6 centimeters, it takes some time. We're going to make sure all of these links here are in the show notes so you can check it out. Meagan: But we only have a few minutes left so I really want to talk about positions, okay? So positions in my opinion can truly change failure to progress. Julie: Yes. If there is a lull in labor, they're getting close to calling a C-section, what can we do about that? Nobody wants to hang out at 4 centimeters forever. Nobody does so what can we do about that? Yes, Meagan? Sorry, go ahead. Meagan: Movement. If you do not have an epidural, obviously movement is a lot more free. Moving around, just walking. Just flat-out walking. If we've got a higher baby and we're trying to get a baby down, really think about that femur rotation turning out. You can walk and sometimes I've had my clients do this little step dance thing where you step really wide and out and then left and right and left and right. We are doing this weird-looking dance thing, but you're grooving. Julie: You're grooving. Meagan: That can really help. Or thinking about really big asymmetrical movements so put your leg up on the bed or on a stool or on a whatever and leaning over. Bigger movements and outward movements. If you have an epidural at this point, same thing. Rotate on your side and really open those knees up really, really wide. Try to keep those movements consistent. If you're exhausted and you have an epidural because you need sleep, I really, really believe in sleep and I think it's very powerful. Find a good position. Sleep in that position and when you wake up, get going. Get active. But every 5 or so contractions, if you can, if not, make it 8, make some changes. It doesn't have to be too dramatic. It sounds weird, but if you are at home, crawling up your stairs. Crawling up your stairs on your hands and knees is weird but it works or standing up and down going from the side– one side going down, standing back up, turning and walking back up, turning around, doing the other side down and coming back up. Those things are going to help. Doing big figure 8's or hip dips. As the baby gets lower, all of those things are really still important. We are going to be less focused on big open wide because now we're going to want to get baby in and then down. So if you think about a pelvis, when the femur rotation goes out, the bottom goes in. Femur rotation in, bottom goes out. Thinking about these movements as you're laboring and as you're working through these things, as you're in these positions. Think about our hips, our pelvis, and even doing some cat-cows in labor is really good. We know there is the flying cowgirl. That is a really good one in labor too to get baby down and in. Julie: Walcher's. Meagan: Walcher's is not as fun, but it can be very good. Julie: It is magical. I've seen it push labor through so well. I had a doctor once at the U come in. I had a client who was 5 centimeters. Baby wasn't looking too great. She had been 5 centimeters for a while and we were doing Walcher's. They came in because the heart rate– Walcher's sometimes makes it hard to get a fetal heart rate so the nurses come in. They were talking about C-section and they were prepping, bringing in all of the C-section stuff for her partner to get ready. They were like, “You can't do this. Baby's heart rate is not tolerating it.” I'm like, “No. It's just not picking up the heart rate.” I'm like, “Okay, just one more contraction.” One more contraction later, she comes up and starts pushing 2 minutes later and her baby is born. the doctors are freaking out because, “Oh my gosh, the bed's not designed to labor like this.” Not everyone, sorry, but those are a little couple of pushbacks I've gotten sometimes. Meagan: It's weird-looking. It's funky. It's uncomfortable. Julie: Yeah. It's curious and some staff at hospitals do not– if they see something new and they don't know about it, they automatically assume it's not good because they need to keep everything in line and to the protocol and all of those things. But yeah, it's just really a magical thing. Meagan: There's also the abdominal lift. You can abdominal lift. I think actively moving through the contraction which can get really hard in that active phase, but through the contraction can actually help. Hands and knees, sacrum, and all of those things. Holy cow, there are so many positions. Julie: Yeah, can I just touch back? When you said about the epidural, I love when you're not resting, I think sometimes it's easy to get discouraged if you want an epidural but you also want to move during labor. I want to expound on that a little bit because you can move with an epidural still and here's how you do it. My favorite labor position with an epidural is sitting up in the throne. You lay the head of the bed all the way up, drop the feet down, then you crisscross your legs. Put the peanut ball under your right leg. Five contractions later, peanut ball under your left leg. Five contractions later, criss-cross your legs again or stretch them out straight and then repeat. Do you know what? There are so many magical ways that that helps. It keeps your pelvis moving and shifting and growing. I swear that is the most magical position for laboring with an epidural because you are upright. Baby is going to move down. The pelvis is moving and shifting so it creates lots of movement and space and I have seen that progress labors relatively quickly to how they have been going before we set up the throne so many times. I love that. I will swear. I will die on that hill. If you are failure to progress and things aren't moving, sit up, drop your legs, get the peanut ball. It doesn't even have to be the peanut ball. Maybe you don't have one in your hospital but stack a couple of pillows but put one leg up. Put your foot flat on the bed so your knee is making a triangle. I don't know how to describe it the right way and then drop it and put the other leg up and then criss-cross your legs then stick them out straight like two little sticks. Meagan: Every five. Every five, have subtle changes. Every five, subtle changes. Keep that in mind when you are laboring. Women of Strength, know that failure to progress is rarely truly failure to progress. We get it. We've been told the same thing. We see it all of the time as doulas. There's more. There's more and don't feel like you have to say, “Okay” to a Cesarean if your cervix hasn't dilated to a certain amount that the provider is wanting. Assuming you and baby are doing well, you can always ask for more time. Okay, we are on a soapbox. We could probably continue for a whole while longer, but Julie, thank you for joining me today and talking about failure to progress and what it is and what it isn't. Julie: You're welcome. ClosingWould you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan's bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link.Support this podcast at — https://redcircle.com/the-vbac-link/donationsAdvertising Inquiries: https://redcircle.com/brands

Subscribe to my Patreon for detailed show notes, including a summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitEnroll in Clear+Free: Your Holistic Solution to Persistent HPVCheck out my free Pregnancy Loss Program over at the Born Free Method Find me on InstagramMidwife Collaborator Program(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Subscribe to my Patreon for detailed show notes, including a summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitEnroll in Clear+Free: Your Holistic Solution to Persistent HPVEnroll in the Born Free MethodFind me on InstagramMidwife Collaborator Program(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Subscribe to my Patreon for detailed show notes, including a summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitEnroll in Clear+Free: Your Holistic Solution to Persistent HPVEnroll in the Born Free MethodFind me on InstagramMidwife Collaborator Program(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Visit my Patreon page for detailed show notes, including a summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitEnroll in Clear+Free: Your Holistic Solution to Persistent HPVEnroll in the Born Free MethodFind me on InstagramMidwife Collaborator Program(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Visit my Patreon page for a detailed summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitJoin the waitlist for Clear+Free: Your Holistic Solution to Persistent HPVEnroll in the Born Free MethodFind me on InstagramMidwife Collaborator Program(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Visit my Patreon page for a detailed summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitFind me on InstagramMidwife Collaborator ProgramEnroll in the Born Free MethodJoin the waitlist for Clear+Free: Your Holistic Solution to Persistent HPV(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Visit my Patreon page for a detailed summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitFind me on InstagramMidwife Collaborator ProgramEnroll in the Born Free MethodJoin the waitlist for Clear+Free: Your Holistic Solution to Persistent HPV(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Visit my Patreon page for a detailed summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitFind me on InstagramMidwife Collaborator ProgramEnroll in the Born Free MethodJoin the waitlist for Clear+Free: Your Holistic Solution to Persistent HPV(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Visit my Patreon page for a detailed summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitFind me on InstagramMidwife Collaborator ProgramEnroll in the Born Free MethodJoin the waitlist for Clear+Free: Your Holistic Solution to Persistent HPV(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

Visit my Patreon page for a detailed summary of these guidelines with links, graphics, and more!#DoNoHarmTakeNoShitFind me on InstagramMidwife Collaborator ProgramEnroll in the Born Free MethodJoin the waitlist for Clear+Free: Your Holistic Solution to Persistent HPV(Looking for my other podcast? Go HERE for The Holistic OBGYN)**Medical Disclaimer: The Holistic OBGYN Podcast is an educational program. No information conveyed through this podcast should be construed as medical advice. These conversations are available to the public for educational and entertainment purposes only.

This week, Dr. Jen is exposing the unknowns and misunderstandings surrounding Plan B, or the morning after pill. From the confusion over its technical term ("emergency contraception") to the stigma and shame associated with purchasing it, Dr. Jen navigates the landscape with empathy and humor. She breaks down how Plan B works, its effectiveness within a specific time frame, and the impact of weight on its efficacy. Debunking myths about Plan B as an abortion pill, she tackles the spread of misinformation by politicians and anti-abortion groups. Dr. Jen also explores alternative options like Ella and the copper IUD, leaving listeners informed, empowered, and ready to spread the truth about emergency contraception.       What's going down:    A breakdown of Plan B and emergency contraception in general    How to access the morning after pill    The science behind how Plan B works and when it is best to take it  Why Plan B is less effective if you have a higher BMI   Alternative options to Plan B: Ella, the copper IUD, and the Yuzpe method    The truth about whether or not emergency contraception is equivalent to abortion   Clitorally OVER politicians fueling false narratives about the morning after pill. See TikTok here!      Thank you for continuing the conversation and calling into the Viva la Vulva Voicemail at (503) 893-2016! Please be sure to rate, follow, review, and remember that nothing is considered TMI around here.        Social & Website   TikTok: @drjenniferlincoln   Instagram: @drjenniferlincoln   YouTube: @drjenniferlincoln   Website: www.drjenniferlincoln.com      Resources    Grab a copy of my book HERE!   Obstetricians For Reproductive Justice      References   The American College of Obstetricians and Gynecologists. FAQ: Emergency contraception. https://www.acog.org/patient-resource...   Edelman, Alison B. MD, MPH; Hennebold, Jon D. PhD; Bond, Kise PSM; Lim, Jeong Y. PhD; Cherala, Ganesh PhD; Archer, David F. MD; Jensen, Jeffrey T. MD, MPH. Double Dosing Levonorgestrel-Based Emergency Contraception for Individuals With Obesity: A Randomized Controlled Trial. Obstetrics & Gynecology 140(1):p 48-54, July 2022. | DOI: 10.1097/AOG.0000000000004717  https://www.nytimes.com/2022/06/30/well/family/plan-b-weight-limit.html  The American College of Obstetricians and Gynecologists. “Practice Bulletin #152: Emergency contraception.” September 2015. https://www.acog.org/clinical/clinica...   https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-says-plan-b-doesnt-affect-existing-pregnancy-changes-label-2022-12-23/#:~:text=Dec%2023%20(Reuters)%20%2D%20The,course%20of%20an%20existing%20pregnancy.https://www.bedsider.org/features/363...   GoodRx. https://www.goodrx.com/blog/plan-b-a-...   Thank you to our sponsors for making this episode possible. Check out these deals just for you:  Green Chef - Get 60% off plus free shipping when you go to GreenChef.com/drjen   Zocdoc - Download the Zocdoc app for FREE when you go to Zocdoc.com/DRJEN Learn more about your ad choices. Visit megaphone.fm/adchoices

Welcome to Episode 26 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 26 of “The 2 View” – Save time charting & code accurately, dementia, PE in pregnancy, and the PCN shortage. PCN Shortage Ault, A. FDA Drug Shortages. Current and Resolved Drug Shortages and Discontinuations Reported to FDA. FDA issues new rule on drug shortages. Community Oncology, 9(1), 34. U.S. Food & Drug. Published April 26, 2023. Accessed May 9, 2023. https://doi.org/10.1016/j.cmonc.2011.12.003 Bendix, A. Shortage of penicillin limits access to the go-to drug for syphilis. NBC News. Published April 27, 2023. Accessed May 9, 2023. https://www.nbcnews.com/health/health-news/shortage-penicillin-limits-access-go-drug-syphilis-rcna81777 Global shortages of penicillin. Shortages of benzathine penicillin. Global Sexually Transmitted Infections Programme. World Health Organization. Who.int. Accessed May 9, 2023. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/stis/treatment/shortages-of-penicillin Dementia Alzheimer's Disease Fact Sheet. Alzheimer's Disease and Related Dementias: Basics of Alzheimer's Disease and Dementia. National Institute on Aging. Accessed May 9, 2023. https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet Home. Alzheimer's Disease and Dementia. Alzheimer's Association. Accessed May 9, 2023. https://www.alz.org/ Silbert, L, Erten-Lyons, D. Memory Loss, Confusion in a 51-Year-Old Fired From Her Job. Medscape. Published March 2, 2023. Accessed May 9, 2023. https://reference.medscape.com/viewarticle/850363 PE in Pregnancy Negaard M. YEARS Algorithm for pulmonary embolism (PE). MDCalc. Accessed May 9, 2023. https://www.mdcalc.com/calc/4067/years-algorithm-for-pulmonary-embolism-pe Stals MAM, Moumneh T, Ainle FN, et al. Noninvasive diagnostic work-up for suspected acute pulmonary embolism during pregnancy: a systematic review and meta-analysis of individual patient data. J Thromb Haemost. 2023;21(3):606-615. NIH: National Library of Medicine: National Center for Biotechnology Information. PubMed. Published December 22, 2022. Accessed May 9, 2023. https://pubmed.ncbi.nlm.nih.gov/36696189/ Thromboembolism in Pregnancy. ACOG: The American College of Obstetricians and Gynecologists. Acog.org. Practice Bulletin, Number 196. Published July 2018. Accessed May 9, 2023. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/07/thromboembolism-in-pregnancy Charting & Coding 2023 Emergency Department Evaluation and Management Guidelines. ACEP: American College of Emergency Physicians. Acep.org. Last Updated: October 2022. Accessed May 9, 2023. https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs American Medical Association. 2023 Emergency Medicine Coding Guide. MDCalc. Accessed May 9, 2023. https://www.mdcalc.com/calc/10454/2023-emergency-medicine-coding-guide CPT Evaluation and Management (E/M) Code and Guideline Changes. AMA: American Medical Association. Ama-assn.org. Accessed May 9, 2023. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf ICD-10-CM Coding for Social Determinants of Health. AHA: American Hospital Association – Advancing Health in America. Aha.org. Published January 2022. Accessed May 9, 2023. https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf Level of MDM (based on 2 of 3 elements of MDM) number and complexity of problems addressed. ACEP: American College of Emergency Physicians – Advancing Emergency Care. ERCODER. Acep.org. Accessed May 9, 2023. https://www.acep.org/siteassets/sites/acep/media/reimbursement/acep---2023-ed-mdm-grid.pdf Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!

Content Warning: Miscarriage       This week, Dr. Jen is giving us the ultimate guide to early pregnancy. Think of it as the "So you're pregnant, now what?" episode. She's answering some fantastic questions from a listener who just found out she's pregnant. From the common symptoms you might experience (like tender breasts and extreme fatigue) to the truth about morning sickness and gender myths and when to announce your pregnancy to the world. Plus, she shares her top tips for finding the right obstetrician for you and why you don't need to break the bank on fancy prenatal vitamins. Whether you're in your first trimester, thinking about conceiving, or just curious about what to expect, this episode is a must-listen!       What's going down:     Common early signs of pregnancy    Morning sickness and nausea   Debunking myths and old wives tales    When to announce your pregnancy    Finding the right OBGYN    Doctor visits and the recommended frequency    Prenatals and tips to avoid bankruptcy    Thank you for continuing the conversation and calling into the Viva la Vulva Voicemail at (503) 893-2016! Please be sure to rate, follow, review, and remember that nothing is considered TMI around here.      Social & Website   TikTok: @drjenniferlincoln   Instagram: @drjenniferlincoln   YouTube: @drjenniferlincoln   Website: www.drjenniferlincoln.com      Resources    Grab a copy of my book HERE!   Obstetricians For Reproductive Justice      References   The American College of Obstetricians and Gynecologists. Practice Bulletin #189: Nausea and vomiting of pregnancy.  The American College of Obstetricians and Gynecologists. FAQ: Nutrition during pregnancy. https://www.acog.org/womens-health/faqs/nutrition-during-pregnancy  Learn more about your ad choices. Visit megaphone.fm/adchoices

In this episode of "Cramming for CREOGs," we weigh in on the hefty topic of Obesity in Pregnancy, as detailed in Practice Bulletin 230. Join us as we explore the nuances in counseling and management strategies for pregnant patients with obesity, and shed light on how to provide the best care for both mother and baby.

In this episode of "Cramming for CREOGs," we explore the lesser-known facts of Antepartum Fetal Surveillance, as outlined in Practice Bulletin 229. Get ready to "kick" up your knowledge on topics like oligohydramnios, fetal kick counts, contraction stress tests, non-stress tests, biophysical profiles, and more.

After weeks of putting it off, Dr. Jen is finally tackling a topic that she's sad and enraged that she even has to address: the need to consider hysterectomies as birth control due to the current abortion restrictions in the U.S. A heavy topic, yes, but at the end of the day, this podcast is a safe space where we can mention it all and have the hard and necessary conversations. So today, Dr. Jen is doing just that and giving the lowdown on hysterectomies, from what they are to the different forms, risks to be aware of, if they really are worth it as a contraceptive after all, and other options to consider before going down that road. So buckle up and brace yourselves for a wild and informative ride!       What's going down:     Breaking down hysterectomies and the different types of procedures available    Why tubal ligation, or "tying your tubes," is a solid form of birth control to consider  Examples of LARCs and their overarching benefits    A walkthrough of how hysterectomies are done and the risks associated with each kind   Hysterectomy aftercare: how you'll feel and what really happens to your organs when your uterus is removed    Why Dr. Jen LOVES the way people are keeping it real about hysterectomy recovery on social media. Watch the TikTok here!      Thank you for continuing the conversation and calling into the Viva la Vulva Voicemail at (503) 893-2016! Please be sure to rate, follow, review, and remember that nothing is considered TMI around here.      Social & Website   TikTok: @drjenniferlincoln   Instagram: @drjenniferlincoln   YouTube: @drjenniferlincoln   Website: www.drjenniferlincoln.com      Resources    Grab a copy of my book HERE!   Obstetricians For Reproductive Justice      References    https://www.nytimes.com/interactive/2022/us/abortion-laws-roe-v-wade.html  https://www.acog.org/womens-health/faqs/hysterectomy  https://www.theguardian.com/media/mind-your-language/2012/mar/08/mind-your-language-feminisation-madness  American College of OBGYN FAQ: Sterilization by laparoscopy. https://www.acog.org/womens-health/faqs/sterilization-by-laparoscopy  American College of Obstetricians and Gynecologists. Practice Bulletin 208: Benefits and risks of sterilization. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/03/benefits-and-risks-of-sterilization     Thank you to our sponsors for making this episode possible. Check out these deals just for you:   Green Chef - Get 60% off plus free shipping when you go to GreenChef.com/drjen   Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Jen is shifting gears to discuss a topic that's a bit more serious this week: vulvar cancer. Although rare, vulvar cancer is very real and can have incredibly unfortunate outcomes if not treated or monitored correctly. As always, Dr. Jen goes (down) there and doesn't hold back on the facts when addressing matters of the vulva, walking us through the diagnosis, treatment options and prevention practices. If you are someone or love someone with a vagina, this episode is a staple to have in your back pocket, providing the knowledge necessary to help stay safe.     What's going down:    The various types of vulvar cancer and their level of commonality   What causes cancer of the vulvar and essential risk factors to be aware of   An in-depth breakdown of colposcopies and the diagnosis process   Treatment options available: surgical and non-surgical   Why self-examinations and vulva surveillance could save your life   What staging is and what it means Tips and preventative measures to consider to keep yourself safe   Discussing the clitorally ridiculous and dangerous misinformation about “lightening” your vulva. Watch TikTok here!   Find out why extreme dieting and lifestyle shifts won't make your HPV go away here.   Thank you for continuing the conversation and calling into the Viva la Vulva Voicemail at (503) 893-2016! Please rate, follow, review, and remember that nothing is considered TMI around here.   Social & Website   TikTok: @drjenniferlincoln   Instagram: @drjenniferlincoln   YouTube: @drjenniferlincoln   Website: www.drjenniferlincoln.com      Resources    Grab a copy of my book HERE!   Obstetricians For Reproductive Justice  References   The American College of Obstetricians and Gynecologists. Practice Bulletin #224: Diagnosis and Management of Vulvar Skin Disorders.   The American College of Obstetricians and Gynecologists. Committee Opinion #675: Management of Vulvar Intraepithelial Neoplasia.  https://www.cancer.org/cancer/vulvar-cancer.html  https://www.cancer.org/cancer/vulvar-cancer/about/key-statistics.html#:~:text=In%20the%20United%20States%2C%20women,will%20die%20of%20this%20cancer  Learn more about your ad choices. Visit megaphone.fm/adchoices

If you have a vagina, the chances that you've experienced a yeast infection are more than likely, and let's face it, they're annoying AF (IYKYK). Today, Dr. Jen is answering two burning (no pun intended) questions about yeast infections, addressing what they are, why you get them, how to treat them, and so much more. We also dive into this week's teachable moment and bust some ridiculous myths along the way. Don't miss it!      What's going down:     What yeast infections are exactly, and what is the most common strain   Common symptoms associated with a yeast infection, the ideal diagnosis, and why self-diagnosis isn't ideal     The difference between an uncomplicated and complicated yeast infection and treatment options for each    Boric acid: what it is, the dangers of using it incorrectly, and best practices for usage     Why using natural remedies to treat a yeast infection isn't always in your best interest    The down low on douching, which vaginal cleansers to avoid, and what's actually safe to use down there     Antibiotics and why you shouldn't jump to conclusions about causing yeast infections     Why the jury is still out on whether probiotics help prevent yeast infections and which ones to use if you do decide to take them   Clitorally cannot believe this was a real ad. Find out why Summer's Eve can kiss my as* here.       Thank you for continuing the conversation and calling into the Viva la Vulva Voicemail at (503) 893-2016! Please be sure to rate, follow, review, and remember that nothing is considered TMI around here.        Social & Website    TikTok: @drjenniferlincoln    Instagram: @drjenniferlincoln    YouTube: @drjenniferlincoln    Website: www.drjenniferlincoln.com        Resources     Grab a copy of my book HERE!    Obstetricians For Reproductive Justice        References    1. The American College of Obstetricians and Gynecologists. Practice Bulletin #125: Vaginitis in nonpregnant patients. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/01/vaginitis-in-nonpregnant-patients   2. http://npic.orst.edu/factsheets/boricgen.html   3. https://www.nytimes.com/2022/04/27/well/vagina-probiotics-supplements.html   4. To find a vulvovaginal specialist: https://www.nva.org/for-patients/health-care-provider-list/   5. My YouTube video on products I recommend for cleaning down there: What to use to clean *down there* **UPDATED** | Dr. Jennifer Lincoln  Learn more about your ad choices. Visit megaphone.fm/adchoices

What's going down:  Discussing the overwhelmingly negative societal outlook on menopause and why we need to do better     Diving into the definition of menopause and what exactly can transpire before and after     Breaking down genitourinary syndrome of menopause (GSM), vaginal atrophy, the symptoms associated, and the power of lube     Hormonal treatments and the differences between local vs. systemic   Benefits and risks of non-hormonal treatment options     Clitorally the most disturbing TikTok on the internet promoting vaginal rejuvenation. Find out why the "Mona Lisa" laser can kiss my a$$ here!     Thank you for continuing the conversation and calling into the Viva la Vulva Voicemail at (503) 893-2016! Please be sure to rate, follow, review, and remember that nothing is considered TMI around here.   Social & Website  Tiktok: @drjenniferlincoln  Instagram: @drjenniferlincoln  YouTube: @drjenniferlincoln  Website: www.drjenniferlincoln.com    Resources   Grab a copy of my book HERE!  Obstetricians For Reproductive Justice    References:  The American College of Obstetricians and Gynecologists. Practice Bulletin #141: Management of menopausal symptoms. July 2014.  The American College of Obstetricians and Gynecologists. FAQ Vaginal rejuvenation, labiaplasty, and other female genital cosmetic surgery.   NAMS Position Statement: The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause: The Journal of The North American Menopause Society Vol. 27, No. 9, pp. 976-992 DOI: 10.1097/GME.0000000000001609  https://www.nytimes.com/2018/07/30/health/vaginal-laser-fda.html  Learn more about your ad choices. Visit megaphone.fm/adchoices

What's going down:    Addressing what exactly abortion medication is, its effectiveness, and the different types available   What side effects to expect when taking these medications at home; what is normal and when to be concerned   The brutal history of accessing abortion pills in the United States and the REMS criteria   Breaking down how and where to safely access abortion medication while minimizing legal risk    Clitorally cannot handle the dangerous misinformation that exists out there surrounding reverse abortion medication. Watch TikTok here.    Thank you for continuing the conversation and calling into the Viva la Vulva Voicemail at (503) 893-2016! Please be sure to rate, follow, review, and remember that nothing is considered TMI around here.    Social & Website   TikTok: @drjenniferlincoln   Instagram: @drjenniferlincoln   YouTube: @drjenniferlincoln   Website: www.drjenniferlincoln.com      Resources    Grab a copy of my book HERE!   Obstetricians For Reproductive Justice   https://www.reprolegalhelpline.org/   Mayday Health   https://safe2choose.org/   https://choixhealth.com/advance-provision/   https://www.womenonweb.org/en/survey/21244/advance-provision-of-abortion-pills   https://aidaccess.org/en/    https://www.plancpills.org/  Digital Defense Fund: Abortion privacy   References   1. The American College of Obstetricians and Gynecologists. Practice Bulletin #225: Medication abortion up to 70 days of gestation.    Learn more about your ad choices. Visit megaphone.fm/adchoices

This episode is exclusively with Meagan and Julie, here to answer your burning questions! Topics include due dates, induction, membrane sweeping, diastasis recti, scar tissue, pelvis size, and head size.We also have a sad announcement to share. Thank you, VBAC Link Community, for being with us through all of our seasons of change and growth. We feel that you are there for us as much as we love being there for you!Additional linksACOG Practice Bulletin 146: “Management of Late-Term and Postterm Pregnancies”Julie Francom Birth PhotographyHow to VBAC: The Ultimate Prep Course for ParentsFull transcriptNote: All transcripts are edited to correct grammar, false starts, and filler words. Julie: Welcome to The VBAC Link podcast. This is Episode 194 and this is Julie. I'm here with Meagan today. We have a not-as-fun of an episode. It's fun because we are going to do some FAQ's. We are going to talk about questions that we get all of the time. We had you guys submit questions on our social media pages, questions that we have been getting through our email, so we are so happy to answer your questions as usual. We also have an announcement to make that is not as fun. But before we do any of those things, Meagan has a Review of the Week for us. Review of the WeekMeagan: Yes, I do. This is from Ashley. She says, “This podcast is a gold mine of knowledge when it comes to VBACs. I have been bingeing these episodes ever since I got pregnant with my second. I have learned so much and gained a lot of confidence on how to find a truly supportive provider. I have enjoyed the birth stories so much. I mostly listen on my commute and can also say that these ladies are my car doulas.”That's fun. Julie: Yay!Meagan: I have cried tears of happiness and/or tears of pain and understanding during so many of these stories. No matter what happens in my birth in August, which I hope will be a VBAC, this podcast has prepared me for it. P.S. I am now caught up on all of the episodes and I am sad that I have to wait for just one weekly episode.” That is so hard. You know what? I have listened to podcasts like that. I am a big– Julie: You just binge.Meagan: I am a big crime podcast listener. I will wait and wait and wait, and then I will catch up really fast, then I'm like, “No. I need to listen any time I want. All day every day if I need to.” It's so hard to wait for the next week's episode. So Ashley, you actually posted this in April. It doesn't say the year. It just says April 27th, so if it was this year and your VBAC is coming really soon–Julie: I think if you double-click the cell, it brings up the year. Meagan: 2021. So Ashley, you– Julie: Already had her baby. Meagan: No, she's due in August. Julie: Girl, it's 2022 right now. Meagan: Oh duh. It's 2022. So Ashley, tell us how your birth went. Julie: We may need to– our admin, Sarah, has left and she was so good at putting all of the new reviews in our spreadsheet. I don't think either of us has done that for a long time. Meagan: I have not. We need some more, so drop us some reviews. Go to Apple Podcasts, Google, or wherever and drop us some reviews. We would love it and very much appreciate it. And Ashley, if you are still listening, we would love to know how things went and we are sending you congrats right now.The VBAC Link's AnnouncementJulie: Aww. Meagan: Okay. Julie: Oh my gosh.Meagan: Ms. Julie, I am turning the time over to you. Julie: No, the time is for you. I don't want to tell them. I don't want to say it. I feel like I am doing something wrong. It's the first time I feel like I'm doing something wrong. Meagan: So, we do. We have some news and the news is pretty crummy in my opinion. Julie is leaving us. She is leaving us. She is no longer going to be with The VBAC Link, although, let's be honest, I'll probably be bringing her back here and there. Julie: Will I ever really be gone? Meagan: Yeah, will you ever really, really be gone? I don't know if I'm going to be able to allow that to happen. But that is the truth. So, Julie, I don't know if you want to share a little bit. Julie: Yeah. Meagan: I don't know if you want to share a little bit. I am just so sad. Julie: Oh my gosh. Yeah. It's sad, but it's the right choice for me. Oh my gosh. I don't know how much I should share or how much is appropriate to share. First of all, there's nothing wrong. Meagan and I are 110% good. I love Meagan. She loves me, at least I hope she still loves me. She hasn't told me otherwise.  Meagan: I adore you. Julie: There's nothing wrong with The VBAC Link or with any– there's no controversy or drama or anything like that. It's just that there are things in my life that have lined up in a way that it doesn't make a lot of sense for me to continue with The VBAC Link anymore. But I am so grateful to Meagan for keeping it forward and I know that she is going to do an amazing job doing that. I'm still in half of the course. I'm still on half the blogs. There are going to be remnants of me.  But yeah. I guess we can just talk a little bit about how I came to this decision. I think a lot of people would appreciate some vulnerability and some honesty here. Maybe a lot of people here just don't care very much and that's totally fine. If you want to know, then definitely stick around, and then we are going to get to answering some VBAC FAQ's. I don't know if it's FAQ. Meagan: Just Q&A's. Julie: Yeah, Q&A's. Those are the right letters. I don't know how much you really know about this, but I had a pretty traumatic childhood with a lot of trauma involved growing up. I have recently been diagnosed with PTSD related to that childhood. I know that a lot of people here can relate to that. Trauma is trauma, right? Whether it happens in childhood, whether it happens in adulthood, whether it happens because of this thing, that thing, or childbirth, or whatever, trauma is trauma. Trauma responses are the same no matter what. Everyone's trauma stories are different, but trauma responses are the same. I have pretty complicated trauma from my childhood that happened for many, many, many years. I thought I was doing fine and coping well through life, and I was because I was really good at stuffing things down, not feeling things, just trucking on, moving forward, and pushing through. That was my identity and then I started having kids because kids bring up– you guys can probably relate to this– all of the emotions, all of the feelings, all of the hormone shifts, and everything like that. Having kids started bringing up all of these things that I have been stuffing down and moving fine and doing comfortably not addressing and ignoring throughout my entire life. And so slowly but surely, I started having a lot of mental health issues. I was doing pretty well but the depression and the anxiety came. My different triggers with PTSD started showing up. It came to a point last year at the beginning of 2021 where I knew that something had to change. Something had to change. I was so anxious. I felt like everything was out of control and was kind of spiraling. I was not doing very good in life and I knew that I needed to be better for myself, better for my kids, better for my husband, better in all of my relationships, better in my partnership with Meagan, a better doula for my doula clients and now, I'm turning into a birth photographer. I started taking charge of my mental health and I went into a pretty big program that took a lot of time which is one of the reasons why we decided to take a break from the podcast because I was investing so much time in my mental health, healing my past, and healing the traumas that I had dealt with so long ago, that we needed a break from the podcast. And so anyway, it's been a little while since things have settled down. I am doing a lot better now, but I am also trying to figure out how to exist. I don't know if that's the right word. How to find the right balance between me while I am still healing– it's probably going to be a lifelong thing. As all people do, we all have our things. We all have our issues to work on, right? I'm just trying to find my balance and what feels right to me. I used to be the person that gets a lot of things thrown at her. I get a lot of things done. I knock stuff out. I accomplish so many things and everybody says, “Oh my gosh, I don't know how you do so much.” Well, I'll tell you how I do so much. I do so much by completely ignoring my self-care, by having a really unhealthy relationship with work and no boundaries with people and things. I'm rediscovering how to find a balance in all of those things. And so I have a lot of priorities right now. First of all, of course, is my family– my husband and my kids. Second of all is myself. My therapist gets mad at me all of the time for not making myself a priority in my life. But I am working on that and that self-care but also, healing and making better and improving constantly those important, eternal relationships to me which are my family and myself. Also, my business is now birth photography so if you are in Utah, I know a girl who can take your birth pictures for you. I'm reidentifying that and giving more to my usual clients as a birth photographer and doula. I am still a doula as well, a doula and photographer together which is called a doula-tog if you didn't know. Doula-togs are a thing now. It's pretty exciting. I've really invested a lot of myself into those areas. I'm improving myself, my relationships, and my other business which has been very fulfilling. Unfortunately, The VBAC Link is the next priority. I say “unfortunately” because after I put all of my time and energy into these other priorities of mine, there's just not a lot left to give to The VBAC Link and it makes me sad to say. I am so sad to say it. I can't continue with the unhealthy relationship with everything that I have had going on in my life. And so this is me setting my healthy boundaries. It has taken a really long time. I think I started really considering it in January and now it's July. It has taken a really long time to get comfortable with that because The VBAC Link has been such a big part of my identity and who I am as a birth worker for so long. It's taken a long time for me to get comfortable with the need to let it go so that I free up myself to put the energy into my higher priorities and the things that matter more and that are more significant in my life. I guess that is the best way to say it but t's hard because The VBAC Link has been so significant. My priorities are kids, the husband, birth photography, and VBAC Link, and then maybe myself, right? So probably that's not a good thing, right? So I need to, yeah. I don't know. I'm just rambling now, but I love The VBAC Link. I love The VBAC Link. I still will always be a founder of The VBAC Link. I still will always have so much love for Meagan, The VBAC Link, and all of you on your journeys. I'll still listen to your stories and keep up with everything that's going on. I'll pop in probably for a podcast here and there with Meagan. But yeah. There's been a huge need for a big personal shift in my life and unfortunately, this is the thing. I don't know what to say.Meagan: This is the thing. It's just one of the things that need to be eliminated. It sucks. It sucks. Julie: It totally sucks. Meagan: It sucks really bad, but I just want you to know how proud of you I am because I know it wasn't an easy choice or decision at all. I know that. I know that it was not easy. I'm not going to let you go too far. Julie: Yeah, we'll see each other. We'll be around. Meagan: Yes. Julie: At births together, probably. Meagan: I'm excited that you're still doing photography and still being in the birth world a little bit and finding your place there, but yeah. I'm going to miss you but don't worry, listeners. You'll still hear her every once in a while.Julie: Yeah, and shoot me a message. You can follow me on, I don't know. Can I do a shameless plug for my business? You can check me out on Facebook or Instagram. Just search for Julie Francom Birth and you can find my Instagram and Facebook.Meagan: Yeah, go find her. Julie: You can reach out to me. I would love to hear from you still because as of now, I am not involved anymore in the day-to-day operations and the messaging, the emails, and all of the intricate things that we do. Meagan: I know, all the things, yeah. Julie: It will be sad, but yeah. Come say “hi”. I would love to hear from you. Meagan: Yes. Let her know that you are still with her. Julie: Yeah. All right, let's get past the sappy stuff. I don't do well with it. Meagan: I know. I'm like, “Can we just not talk about this right now?” I'm not accepting this right now. Q&A'sMeagan: We do. We have questions that some of our followers have asked and it's interesting. One of the questions that we saw come up is truly one of the most common questions that we get, I think. I think it's one of the most common things. It's about due dates. I shouldn't say it's one of the most common, but we had a question asking about a provider who is wanting her to have her baby immediately because they want to avoid a big baby. They want to know how far or if it's even okay to go past your due date. Gosh, Julie. I struggle with this one a little bit because don't you feel like it's ever since the ARRIVE study? Julie: Yeah. Gosh. You know, I feel like it is. I feel like it's more so. There's more pressure on due dates. There always has been, but I feel like everyone wants to induce. Everyone wants to put a lot of pressure on you. Not everybody, but there are a lot of places and a lot of places I wouldn't have expected to do that. Meagan: Yeah. Yeah. I don't know. It just seems like this due date is such a thing. You know, with due dates, it's one of those things that you have to do what's best for you and follow your heart but these providers are wanting to induce. And so I'm actually going to steer away– because there were two kinds of questions in regards to due dates. One was “How far past my due date am I okay to go?” But there was another one saying that they want to. I'm trying to look for it right here. Julie: I have something about what ACOG says in our files somewhere. I'm going to find it about due dates. Meagan: Oh, it was stripping the membranes. It was stripping the membranes because the doctor– and this is at 38 weeks. The doctor was wanting her to go into labor immediately, like ASAP, and wanted her baby to be smaller. It was a big baby versus a small one. It is a small part of VBAC stats. I just want to talk about membrane sweeping, inducing, and due dates. I'm going to talk about three of those things. Julie: All of it. Meagan: All at the same time because they kind of all go into play with one another, right? So let's talk about stripping membranes. Sweeping a membrane or stripping a membrane is where your provider will go in and separate the membrane. They go into the cervix, separate the membrane, and sweep around. It releases prostaglandins and hormones to help labor start. However, it doesn't always happen like that. It doesn't just start all the time. I wanted to talk about what it looks like. I don't know if there are actually any stats. Julie, you guys, this is going to be really hard because Julie is such a stat person. I'm going to be writing to her all the time and be like, “Are there any stats that you know about this?” I don't know about the stats or the actual percentage of if it's going to work or not, but this is just a good rule of thumb for considering membrane sweeping that a midwife a long time ago gave me. I'll tell you and you can take it with what you want. So if the cervix is “primed”, and I am doing primed with quotations. If the cervix is looking ready, this is the rule of thumb she gave me. It's 2-3 centimeters dilated, 70-80+% effaced, and the cervix has come at least midline meaning your cervix is not really posterior. It's not really hard to reach. It's lining up more with the birth canal. It's mid. If those things are happening, a sweep is usually something or could be something that may be more effective and bring on labor with a sweep. However, if we are 1 centimeter dilated, 50% effaced, the cervix is really far back there and really not showing signs of readiness, then the chances of a sweep working are a lot lower. And so at 38 weeks, a provider stripping membranes already at 38 weeks, there is a good chance that the cervix will not be “primed” or in an ideal position for a sweep to bring labor on. Some of the pros of sweeping membranes are that it can completely skip an induction because it can work. It can work and people can go into spontaneous labor with that. It's great, right? We don't have to use Pitocin and do those types of things. However, if your cervix isn't super ready and we do a sweep, it could cause something called prodromal labor. Julie knows what prodromal labor is really well because she had, did you say weeks, Julie?Julie: Yeah, it was three weeks. Meagan: Yeah. Three weeks of prodromal labor which is where your body is contracting and acting as though it is trying to go into labor, but it never really turns the curve or the point actually to begin labor. That can leave for very, very, very exhausted mamas, so when labor does kick in, we are tired and do not want to labor, right? So it can bring on prodromal labor because it stimulates the cervix and the uterus just enough to think that we are going to try but because our body's not ready, it can just contract, contract, contract with no real end result of a baby for a long period of time. So those are some cons and pros. Also, the more sweeping and the more things we have in there, the more we are introducing potential bacteria and things like that. Back in the day when I was expecting, my midwife actually offered to sweep my membranes and because I have a history of PROM, premature rupture of membranes, with labor not beginning, I was a little nervous because I was worried that it might weaken my sac or introduce bacteria because I had a provider a long time ago, while I was preparing, say something like, “Your membranes may have been weakened and broke,” so I don't know. There aren't any stats on that that I know of necessarily, but I just didn't want anything extra introduced. So you've just got to take that into consideration as well that you are putting bacteria in and introducing potential bacteria if you are doing a membrane sweep. But it can be something to help avoid induction and if you've got a provider that is saying, “Hey, we are going to schedule a C-section because we are not having a baby,” then maybe that is going to be a good alternative. Julie, I've heard your mouse clicking. Did you find the stat that you wanted?Julie: Yes. It's ACOG's guidelines for postterm pregnancies and induction. This is Practice Bulletin 146. It's called “Management of Late-Term and Postterm Pregnancies”. What I think is really interesting is that this opinion hasn't changed after the ARRIVE trial. They actually reaffirmed their stats on postterm pregnancies after the ARRIVE trial was published. So I really like it. There are two things that I wanted to talk about in relation to the induction of labor. First of all, they say at the very last page, it's the very last section of the bulletin, they talk about TOLAC, vaginal birth after Cesarean, and management of postterm pregnancies. They say right here that– actually, I'll just read it. Well, I don't want to read all of it because it's really long. Okay. “For women who desire TOLAC and who have not had a prior vaginal delivery, awaiting spontaneous labor as opposed to undergoing labor induction most likely avoids further additional increased risk of uterine rupture. Thus, TOLAC remains an option for women with postterm pregnancies who have not had a prior vaginal delivery, but these women should be counseled regarding these unusual risks** such as failure of TOLAC and uterine rupture.”So it says in their bulletin right there that basically these guidelines that they are talking about apply to women even if they have had a prior Cesarean delivery and desire a TOLAC or a VBAC. The second one, or actually there are two other things I want to say. There is a Cochrane review that they site. A Cochrane review is a meta-analysis of several studies. I love Cochrane reviews. They are my favorite types of studies and data because they are usually very, very reliable. They talk about the different outcomes between expectant management and induction of labor. Now, this is before the ARRIVE trial, and remember, the ARRIVE trial is just one single study. Cochrane reviews look at many, many studies and gather the outcomes of all of the studies. I love this because a lot of times, you'll hear providers say, “Oh, your risk of rupture increases after 40 weeks. Your risk of stillbirth doubles.” They're talking about relative risk versus absolute risk. The risks for those are very, very, very small still. We are talking about .002% of stillbirth to .004% of stillbirth. And yes, that technically doubles, but it is still a very small risk. Knowing the numbers and knowing what risk you are assuming is very important when you are making decisions for your birth. I like this because it says, “The number of inductions of labor needed to prevent one perinatal death (or one stillbirth) is 410.” So you would need 410 inductions to eliminate one perinatal death. It says, “There are no incidents in the rates of neonatal intensive care admission in this study”, so your baby is not necessarily more likely to need NICU time for induction. That was a review of 10 trials, so over 6,000 infants. Basically, they summarize at the end. They say, “In summary, based on available evidence, induction of labor between 41 weeks and 0 days and 42 weeks and 0 days can be considered** and an induction of labor after 42 weeks and 0 days is recommended given evidence of increased perinatal morbidity and mortality.” So here, ACOG itself says that looking at all of the evidence, it's safe to go to 42 weeks of pregnancy before recommending a routine induction of labor due to postterm pregnancies. But we have this sudden influx of people rushing to induce at 39 and 40 and even 41 weeks. A lot of people, even my clients will say, “I'm not comfortable inducing before 41 weeks, but if I get to 41 weeks, I'll probably induce.“All of the evidence out there says you may be safe to go on a little bit longer. But of course, we always advocate for you using your intuition, taking all of the evidence, and making a plan that feels best for you and your baby. But yeah, that's what ACOG says. Evidence applies. And I love how after, they say, “Sure, yeah. Going between 42 weeks and 0 days and 42 weeks and 6 days, that's when we are going to recommend it.” And then afterward, they go on and affirm and say, “Yeah. This is even for VBAC too. It's for people who want a trial of labor after a Cesarean. Meagan: Yeah. What's interesting is that for this follower, the doctor is wanting to start inducing-type processes at 38 weeks. And I'm like, “Why at 38 weeks? Why are we starting so early?” But it's because we are seeing this shift. It seems like the 41-week mark is just going away. It's like 39 is 40 and 40 weeks is 41. It's like 41 is nonexistent. It's too far. I don't know. That's just how it feels to me. Julie: Yeah. I see that too. Meagan: Yeah. Yeah. Okay, so another question is “First child was breech, so the C-section delivery took place. Currently pregnant with number two and my doctor moved my due date up one week versus last missed period calculation. Due to baby's size on ultrasound, from what you know, how much past my due date, whichever one is still safe?” Look, I'm reading the same question. So yeah, we just talked about that. Okay, let's see. “I have had an emergency C-section as my baby had their cord wrapped around their neck three times and their heart rate was dropping. I was not able to go into labor at all, so what is the likelihood of that happening again? I really want a VBAC but am worried as I never went into labor.”Julie: Hey, I never went into labor. Meagan: Exactly. I never was able to have a chance to go into labor either. Just because you didn't go into labor once does not necessarily mean you are never going to go into labor again. I am a true believer that people's bodies don't just hold on to babies for life. I do believe that we will all go into labor eventually. I'm sure there are those random cases somewhere out there that maybe babies were carried longer or something, but yeah. The likelihood of your body not going into labor is low. The likelihood or the chance of your body going into labor before a provider may want you to go into labor– does that make sense what I am saying?Julie: Yeah your provider might want you to go into labor before your body is going to be ready. Meagan: Before your body is ready, yes. And there is a chance that your body will not go into labor by the time your provider is wanting you to go into labor, but that doesn't mean you are not going to go into labor. You are likely going to go into labor and it's just a matter of trusting and waiting for your body to get there. So yeah, that would be my answer to that. Julie, anything that you would add?Julie: Sorry, I forgot the actual question. I was just following along with you. Meagan: The chances of her not going into labor. Julie: Oh my gosh, yeah. Meagan: She had a C-section baby. Heart rate was dropping. It looks like the cord was wrapped around their neck. She is wondering what the chances are of her not going into labor.Julie: Yeah, no. Honestly, I don't know if there is a statistic for that. I remember one case a really, really old long time ago where there was a woman that had, oh my gosh. I don't even remember. I can't even speak educated about this. Meagan: Pregnant for a long time. Julie: She was pregnant and the baby had passed around the 20th or 30th week and she didn't know. The baby was in there for decades. Meagan: Oh. Oh, I think I remember that I have heard a story about that. Julie: Do you remember that? There was one. There was one time that that happened. There might be more, but we are talking about one-offs here. The odds that your body is just not ever going to go into labor are highly unlikely. This is also speculation, but I have a couple of my IVF moms who have had to get pregnant through IVF and needed a lot of help getting pregnant say that their fertility providers, and I am not an expert in fertility anything, but I've had a couple of my clients that have gone through IVF say that if their body has problems producing the hormones to get you pregnant, it might have problems with the hormones needed to go into labor. Meagan: Yeah, I've heard IVF and things like that might need–Julie: They might need Pitocin. They might need a little nudge or higher doses of Pitocin.Meagan: Yeah, they are suggested to be induced due to other things. Julie: Yeah. Meagan: yeah. Julie: But even that is a little bit like maybe, like maybe, but I don't know. I don't think there is anything inclusive to say one way or the other in that regard. If there is, definitely let us know or let Meagan know. Message me too, I guess. Let The VBAC Link know.Meagan: Let The VBAC Link know and I will make sure that Julie knows. Julie: Yes. I want to be educated still. Meagan: Yes. Okay, so another question is “What role does diastasis recti play when it comes to a successful VBAC?”So if you don't know what diastasis recti–Julie: Diastasis?Meagan: Diastasis. I always say diastasis. Julie: I don't even know how to say it right. You may be right. I don't know.Meagan: I bet it's diastasis. That sounds more medical. Julie: You know what we're talking about, right people? Meagan: Yes. That is the separation of the abdominal wall.  Julie: The abdominal muscles, yeah. Meagan: Yeah. I don't know if it necessarily plays any role specifically as far as having a VBAC. Have you ever heard of anything like that? I mean, I had a diastasis recti and I had a VBAC after two C-sections. You might have more pelvic pain because mine caused pelvic pain. This is actually a really good question for Gina or our pelvic floor specialists. I'm actually going to write that down. We are going to have a pelvic floor specialist on. I'm going to write that down and ask that question, so come back to that. Julie: Yeah. Meagan: Yeah because I don't actually know if it does. I don't think it does. Julie: I don't think it does either. I haven't heard of anything like that. Meagan: Yeah. Julie: To me, the abdominal muscles and the uterine muscles are completely separate from each other, but it might impact your pelvic alignment. You might need to take extra care to go to a chiropractor and see a pelvic floor specialist to make sure all of your connective tissues are nice and loose to go into labor. That's just where my mind goes. Meagan: Yeah, yeah. It might cause more discomfort but not necessarily make your chances go down of having a VBAC is what's in my head. I will try and get that confirmed. Okay, let's see. What other questions? I don't know if you're on it. Oh, “what happens to Cesarean scar tissue after you've had a VBAC? Do the intense stretching and shrinking help remove adhesions or does it re-adhere?”Personally, I have dense adhesions and they just continue to come. If I don't actively work out my adhesions and my scar, I just continue to get adhesions and I can feel them. It's weird but I can feel them. So once you've had a VBAC, I mean, I've had a VBAC and mine are still coming. I would say that you still probably need to seek pelvic floor specialists or learn how to properly massage your scar. It says, “Do the intense stretching and shrinking help remove adhesions?” I mean, it could maybe stretch it out, but I don't think it removes.Julie: Yeah. Yeah. Meagan: Yeah, but again, I'm going to throw that one into our pelvic floor specialist episode that's going to be coming up because I don't know the exact answer on that. I just don't know. But from my experience of being seen, the answer is no, it doesn't necessarily shrink or remove adhesions. Julie: Mhmm, yeah. There's a way to make them more flexible. Everything you say, yes. I'm just going to echo everything. Meagan: You can work them out. Julie: Yeah and make them more flexible and pliable, but there's no real way to get rid of them unless you go in and surgically remove them, but then surgically removing them causes more of them so it's kind of a double-edged sword there. Meagan: Yeah, that's a hard thing. Once you've got that scar there, you've got it. And adhesions come with any type of scar. It doesn't just mean C-section either. It's really any type of scar. Okay, so it says, “My first pregnancy was last June and that baby was a C-section. I'm now expecting in November. The reason I needed an emergency was because my son wouldn't come down due to my pelvis being too small. When I spoke to my new OB about a VBAC, she told me that I wouldn't be–” Can you hear my thoughts as I am reading this?“When I spoke to my new OB about VBAC, she told me I wouldn't be a good candidate due to my pelvis being small,** that the size will never change, and I will have the same issue as I did with my second child. I just wanted to know if this is true.”Meagan: Um, no. Julie: No. Not true. Meagan: Not true. Not true. Not true, not true, not true. I was also told that my pelvis was too small and I would never get a baby out of it. Julie: So was I. A 4lb, 10 oz C-section baby. My VBAC baby was 8lb, 9 oz with a 99th percentile head. How is my pelvis too small for a baby that size?Meagan: Yes. Let's talk about heads. There was a question talking about head size. Oh my gosh, I want to see if I can find it. Let me see if I can find it. I'm scrolling through. Julie: We need to get wrapping up, actually. Meagan: I know we do. Oh my gosh. Julie: Unfortunately. Meagan: So no, no, no. You still have a chance. I'm so sorry. I'm going to be blunt, but your provider's just not being supportive. It's really, really, really hard to diagnose a small pelvis and it's really rare, so I would say it was more likely due to position or maybe just not enough time or something like that versus the fact that your pelvis was actually too small. And oh my gosh, there was a head question and I can't find it, but I want you to also know because I swear it was something about babies with big heads not fitting out. My baby and Julie just mentioned it, but my babies all have ginormous heads. My VBAC baby had a 99th percentile head. I always say that it's because they are brilliant. He still has a big head and a tiny body. It's kind of funny. He's just small but he came out just fine. No tearing, totally fine. It's a lot of the time positioning. Julie: Yep.Meagan: We have lots of questions that we still didn't get to, but don't worry.Julie: I'll have to come back sometime for another Q&A.Meagan: Yes. I will be doing more of these and Julie is just going to have to come back. Julie: And seriously, come and say “hi”. I would still love to talk to and connect to people. Especially if you are in Utah and local, come see me at the ICAN meetings, the ICAN of Utah County. Follow my Instagram and Facebook pages and Julie Francom Birth. I still am going to be a major VBAC advocate and a big part of helping women just a little more locally here. Meagan: Yes. Julie: I'll come and say “hi”, I promise. Meagan: Yes, okay. Well, Julie, I don't know what it's going to be like without you. I really don't. Julie: It's going to be strange. I don't know what my life is going to be like either. I'm going to have, I don't know. I'll spend time with my kids and be able to actually enroll them in sports again. Meagan: Yeah, no. I'm not loving it. Not loving the thought of it, but I am proud of you.Julie: You are sweet. Meagan: And I want you to know how much I love you. I've enjoyed this journey with you and I just hope that I can keep this afloat without you. Julie: You will. I'm 110% confident in you and you know I'll always help you out if you need it. Meagan: Well, thank you. Julie: Goodbye, signing off. I don't know. Bye! I don't know what to say.ClosingWould you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Julie and Meagan's bios, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link. Advertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

Practice Bulletin #136 - Published July 2013 (Reaffirmed 2017) 1. Know your reproductive endocrinology like the back of your hand! 2. AUB-O is classically associated with cycles that differ in length by `10 days or more. Patient with AUB-O also generally don't experience the classical cyclical breast tenderness, mucoid cervical discharge, premenstrual cramping, or bloating seen in ovulatory bleeding. 3. Anovulation is the most common etiology of AUB in 13-18-year olds. Transfusion or hospitalization is rare in this age group, but, when it happens, you should investigate coagulopathy. 4. AUB-O in patients >18 years of age should prompt investigation for hyperplasia/malignancy. 5. Hysterectomy or hormonal contraceptives are the mainstays for treating AUB-O, but neither address the underlying endocrine abnormality. 6 .SIS + EMB is a sweet combo: if both are negative, the likelihood of pathology is extremely low and conservative measures are be offered without you losing sleep Show Notes Theme music by Evan Handyside

Practice Bulletin #135, Published June 2013 (Reaffirmed 2017) 1. It's none of your damn business why a woman desires a 2nd trimester abortion. There are also a lot of scenarios in which 2nd trimester abortion skills are necessary but that have nothing to what many perceive to be a seemingly easy decision to terminate a pregnancy. 2. If you don't feel confident in your skills as a provider to perform 2nd trimester abortions, do your patients the service of developing a referral relationship with another provider who does. 3. Inducing fetal demise prior to 2nd-trimester abortion does not improve safety or decrease procedure time in case of D&E, but he it does shorten induction time for medical abortion. 4. Misoprostol + mifepristone = the most effective protocol of medical options 5. All methods of contraception are effective on the day of 2nd-trimester abortion apart from cervical cap, diaphragm, or hysteroscopic sterilization (including IUD) Show Notes Theme music by Evan Handyside

Practice Bulletin #1114, Published July 2010 (Reaffirmed 2018) 1. Pelvic pain and infertility are characteristic. Severe dyspareunia and dyschezia are indicative of deeply infiltrative disease. 2. The etiology is unknown, but currently thought to be due to the implantation of endometrial glands and stromal cells outside the uterus within the peritoneal cavity due to retrograde menstruation 3. Histologic evaluation of a surgical specimen is the gold standard for diagnosis. Visualization of endometriotic lesions has a high false positive rate. The finding of an endometriomas on imaging studies can alone be highly predictive, though. 4. Excision of endometriosis can improve fertility rates, particularly with the excision of an endometrioma. 5. NSAIDs, COCs, GnRH analogues, and progestins are all great alternatives to surgery for managing endometriosis-related pain Show Notes Theme music by Evan Handyside

Practice Bulletin #183, Published October 2017 w/ co-host Sara Rosser, CPM (@sararosser) 1. PPH is defined as 1000 mL for either vaginal or cesarean birth. 2. Go with your gut in diagnosing PPH, and do it fast! You can't rely on vital signs or lab work to make the call to action in the acute setting. 3. Uterine atony is the most common cause of PPH. Manage through uterine massage, uterotonics, tamponade, and UAE. Opening up her abdomen to place compression sutures, ligate the uterine vessels, or perform hysterectomy are last resort! 4. Remember the triad of the amniotic fluid embolism: respiratory decompensation, hemodynamic instability, and DIC. 5. As soon as you feel that she's lost too much blood activate your institution's transfusion protocol. Remember that you can never get pre-screened blood fast enough when you actually need it. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Theme music by Evan Handyside

Practice Bulletin #175 - Published December 2016 (Reaffirmed 2020) w/ co-host Sara Rosser, CPM (@sararosser) 1. US may be harmful if overutilized. 2. Important uses include pregnancy dating/viability, fetal growth, and amniotic fluid assessment. 3. US pregnancy dating is most accurate in the 1st trimester. If significant discordance exists between US dating and LMP dating, it may be appropriate to adjust due date. 4. Fetuses at risk for FGR should be monitoring by serial growth ultrasound. It's not recommended to repeat growth ultrasound more frequently than q2 weeks. 5. Growth-restricted fetuses can be monitored through umbilical artery Doppler velocimetry as a means of avoiding bad perinatal outcomes. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Theme music by Evan Handyside

Practice Bulletin #129 - Published September 2012 (Reaffirmed 2016) 1. In any hypoestrogenic state, resorption begins to overwhelm building, leading to decreased bone density. 2. Treatment is warranted if T-score ≤ 2.5 on DXA scan or if patient has history of vertebral facture or other type of fragility fracture 3. FRAX tool can be helpful in determining usefulness of treating patients in the osteopenic range (T-score < - 1 to ≥ -2.5). It predicts risk of osteoporotic fracture over next 10 years . 4. Bisphosphonates are first-line therapy for all-comers, though raloxifene is also reasonable first-line in younger postmenopausal women. 5. HRT is a great alternative to bisphosphonates in younger women at risk for osteoporotic fracture: ~35% decreased risk of hip fracture (estrogen alone or estrogen + progestin) Show Notes Wine pairing: 2017 Tempranillo from Baron de Ley Varietales Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #132 - Published December 2012 (Reaffirmed 2017) 1. The clinical diagnosis of APS is made through a careful clinical history that takes into account thrombotic events, history of pregnancy loss, and development of preterm preeclampsia. 2. Lab studies to detect specific antibodies can confirm your diagnosis, but these lab studies are not indicated when clinical criteria are not met. 3. The three relevant antibodies on your board exam are: lupus anticoagulant, anti-β₂-glycoprotein, and anticardiolipin 4. The worst consequence of APS is thrombosis. 5. In pregnancy, thrombotic risk is EVEN higher. APS patients with history of thrombosis should be treated with prophylactic heparin throughout pregnancy until 6 weeks postpartum. Show Notes Wine pairing: 2018 Sonoma Zinfandel from Seghesio Family Vineyards Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #128 - Published July 2012 (Reaffirmed 2016) 1. "Normal menstruation" is classified by ACOG as: 5 days of bleeding with cycle length of 21-35 days 2. PALM-COIEN is a classification system for abnormal uterine bleeding. 3. Get good at SIS and hysteroscopy! A meta-analysis found intrauterine cavitary anomalies in roughly 50% of women with AUB 4. Fibroids tend to present as heavy periods. Polyps tend to present as intermenstrual bleeding. Adenomyosis presents with painful and heavy periods. 5. Accuracy of blind endometrial biopsy is great if (a) an adequate sample is collected and (b) the endometrial process is global. A blind EMB can miss cancer if less than 50% of the endometrium is involved. Show Notes Wine pairing: 2018 Cabernet Sauvignon from Los Vascos Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

The ACOG will release a new Practice Bulletin in June 2021 discussing obesity in pregnancy. The prevalence of obesity in reproductive age women in the United States is 39.7% In this session we will review some key practical issues regarding cesarean sections in the obese patient. Is one type of skin closure better than the other? What is the optimal VTE pharmacological protocol? Tune in and see!

Practice Bulletin #169 - Published October 2016 (Reaffirmed 2016) w/ co-host Sara Rosser, CPM (@sararosser) 1. Multifetal gestations have overall increased risk of morbidity for both mom and baby. 2. Chorionicity is an important piece of information for managing these pregnancies. Monochorionic pregnancies carry higher risks than dichorionic pregnancies. 3. Outside of dx of cervical insufficiency: available data doesn't support cervical cerclages, bed rest, tocolytics, or pessaries decrease morbidity or mortality associated with preterm birth in setting of multifetal gestation. 4. NIH recommends administration of corticosteroids for any pregnancy, irrespective of GA, at risk of birthing from 24-34 wga within 7 days 5. Unless monoamniotic, twin pregnancy is not a preclusion to vaginal birth Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Red Blend from King Estate Winery Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #156 - Published December 2015 (Reaffirmed 2018) w/ co-host Sara Rosser, CPM (@sararosser) 1. Women with obesity are at increased risk for fetal congenital anomalies, c-section, preeclampsia, fetal macrosomia, childhood behavioral/developmental issues, and other bad outcomes. 2. Pre-conception weight loss to normalize BMI improves maternal and neonatal outcomes. 3. Weight loss while pregnant is not recommended. 4. There are a variety of special considerations intrapartum and postpartum for women with obesity. 5. If your patient undergoes c-section, a thick subcutaneous fat layer should be well-irrigated and approximated with sutures in multiple layers if necessary. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Bourbon Barrel-Aged Cabernet Sauvignon from Ménage à Trois Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #146 - Published August 2014 (Reaffirmed 2019) 1. When pregnancy goes beyond 41 wga, there are increased risks for mom and baby, but absolute risk is overall still very low. these risks are still low in absolute. 2. Pregnancy dating by LMP combined with early ultrasound is far more reliable than LMP alone. 3. "Membrane sweeping" decreases the chance of a pregnancy going beyond 41 wga, but consent your patient first! 4. If fluid checks out, particularly if BPP is otherwise reassuring, it's reasonable to continue pregnancy 5. IOL at or beyond 41 wga does not improve fetal or neonatal outcomes apart from a possibly lower risk of meconium aspiration syndrome. NNT = 410 to prevent one perinatal death. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: Dark Side Red Blend from 7 Moons Wine Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #126, Published March 2012 (Reaffirmed 2016) 1. Rapidly dividing cells - like those in the gonads - are the most susceptible to chemo, so suppressing with GnRH analogues prior to chemo may be protective against ovarian toxicity, but data is mixed. 2. BRCA mutation carriers are at increased risk for both breast and ovarian cancers, therefore prophylactic BSO is recommended at age 40 or after childbearing is complete 3. 5 years of tamoxifen use decreases the annual risk of recurrence by 40% and annual mortality risk by 35% 4. Women treated for breast cancer are at higher risk for bone fracture because chemotherapy, ovarian suppression, and, especially aromatase inhibitors all lead to bone loss and osteoporosis. 5 .HRT has a bad rap historically due to concern that it may predispose women to de novo breast cancer or recurrence, but the findings have been mixed and generally not statistically insignificant. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Perlita Malbec-Syrah from Bodega DiamAndes Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #187, Published May 2017 (Reaffirmed 2016) 1. Neonatal complication risk is overall low (5%), including brachial plexus injuries, clavicle fracture, humerus fracture. HIE/death are also possible, but extremely unlikely. 2. The faster that a shoulder dystocia is resolved, the less likely HIE/death. 3. It's nearly impossible to predict shoulder dystocia, but risk seems to be higher with larger fetuses and diabetic mothers. 4. Insufficient evidence to conclude that early induction of labor when fetal macrosomia is suspected decreases the risk of shoulder dystocia. 5. Steps to resolving shoulder dystocia per ACOG: stop pushing, McRobert's maneuver w/ head traction, suprapubic pressure, rotational maneuvers, then posterior arm delivery. My advice? Get her on all fours way before any of the other maneuvers (Gaskin maneuver). Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Central Coast Red Blend from Smith & Hook Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #101, Published January 2010 (Reaffirmed 2016) 1. Most COCs combine a progestin (i.e. synthetic progesterone) for contraceptive effects with 10-35 mcg of an estrogen (usually ethinyl estradiol) to stabilize the endometrium and reduce unwanted spotting 2. COCs are a safe bet for management of heavy menstrual bleeding. If patient responds to COCs, they are most cost-effective for the first year, then it's more effective to switch to a levonorgestrel intrauterine system 3. The levonorgestrel intrauterine systems work better than progestin-only pills (e.g. norethindrone acetate) to reduce heavy menstrual bleeding and patients report greater satisfaction. 4. DMPA and the progestin IUD can regulate the menstrual cycle over the long haul, but will initially increase the irregularity of bleeding. 5. Before prescribing any hormonal contraception, review the US Medical Eligibility Criteria for Contraceptive Use. Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2018 Pinot Noir from Tres Palacios Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #105, Published July 2009 (Reaffirmed 2017) 1. Combined oral contraceptives may be poorly absorbed in patients who have undergone malabsorptive bariatric surgery (e.g. Roux-en-Y) 2. Micronutrient and macronutrient deficiences are common in pregnancy after Roux-en-Y. These include iron, calcium, vitamin B12, protein, folate, and vitamin D. It's reasonable to screen widely for nutrient and micronutrient deficiencies pre-pregnancy or early in pregnancy and supplemental as appropriate. 3. For patients who underwent a banding procedure, early consultation with a bariatric surgeon is recommended in order to actively manage the band 4. Dumping syndrome is caused by ingestion of refined sugars that are rapidly dumped from the stomach into the small intestine; this causes hyperinsulinemia -> hypoglycemia -> tachycardia; otherwise characterized by bloating, nausea, abdominal pain, n/v, and diarrhea. 5. Patient with dumping syndrome can be screened for GDM by regular glucose fingerstick checks at 24-28 wga Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2017 Pinot Noir from Ferrandière Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #95 - Published July 2008 (Reaffirmed 2017) 1. Normal physiologic changes in pregnancy that are relevant in anemia include increased blood volume, increased red blood cell mass, and increased iron stores. 2. Low serum ferritin is the most sensitive and specific single lab finding in iron deficiency anemia. 3. The CDC recommends universal screening for iron deficiency anemia in pregnancy along with universal supplementation. 4. B12 deficiency and folic acid deficiency are common causes of macrocytic anemia; folic acid deficiency much more likely than B12. 5. Blood transfusions are almost never indicated in pregnancy, apart from the rare case of a large, concealed placental abruption (Hgb non-reassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilation, and fetal death) Show Notes **Visit our friends at The Labor of Love Co. to send a pregnant person in your life a curated maternity or postpartum care package!** Wine pairing: 2018 Red Blend from Horse Heaven Hills Wine Growers Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #91 - Published October 2009 (Reaffirmed 2016) 1. E. coli are the most common bug in UTI. 2. Presence at at least 1,000 CFU/mL on culture or presence of leukocyte esterase or nitrite on UA, particularly if bacteria 2+ or greater in a symptomatic patient is pretty much a slam dank for UTI diagnosis 3. 3-day antibiotic course is sufficient for uncomplicated acute cystitis (trimethoprim-sulfamethaxazole is the preferred agent) 4. Treatment of pyelonephritis can be done as outpatient unless patient is very sick, in which hospitalization w/ parenteral antibiotics may be warranted 5. If symptoms persist beyond 7 days of antimicrobial therapy or if clinical condition worsens, further evaluation through repeat cultures and contrast imaging may be warranted. Show Notes Wine pairing: 2018 Cabernet Sauvignon from La Freynelle Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #86 - Published October 2009 (Reaffirmed 2016) 1. Poorly controlled asthma is associated with prematurity, preeclampsia, growth restriction, and maternal morbidity and mortality. 2. Nonselective β-blockers, carboprost, ergonovine, indomethacin, misoprostol, and dinoprostone can trigger bronchospasm, and they are all commonly used agents in pregnancy/postpartum. 3. Short-acting β2-agonists (e.g. albuterol) are the mainstay for acute asthma exacerbations 4. Long-acting inhaled corticosteroids and inhaled long-acting β2-agonists are the mainstays of maintenance asthma therapy. Oral corticosteroids may be required in the most severe cases. 5. For pregnant patients with poorly-controlled asthma or asthma classified as moderate or severe persistent, fetal growth should be monitored by serial ultrasound beginning around 32 wga. Show Notes Wine pairing: 2019 Chardonnay from Sean Minor Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #84 - Published August 2007 (Reaffirmed 2018) 1. Most patients who die from PE do so within 30 minutes of the event, so prevention is key. 2. If a patient is known to have Factor V Leiden mutation or prothrombin gene mutation 20210A, they should be considered high risk and managed appropriately intra- and post-operatively and in pregnancy 3. Compression stockings, pneumatic compression devices, and pharmacologic prophylaxis are all safe and useful in preventing VTE 4. Highest risk patients benefit most from a combined approach of mechanical or stocking prophylaxis combined with pharmacologic prophylaxis 5. Platelet inhibitors should be stopped 14 days before spinal or epidural anesthesia, unfractionated heparin or twice daily low molecular weight heparin 8-12 hours before, and low molecular weight heparin 18 hours before Show Notes Wine pairing: 2019 Les Quatre Cepages from Domaine de Pajot Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #81 - Published May 2007 (Reaffirmed 2018) 1. Both resectoscopic and non-resectoscopic techniques are safe and effective. 2. Size and shape of the uterine cavity and the presence of fibroids may impact efficacy of non-resectoscopic techniques 3. With resectoscopic techniques, careful monitoring of distension medium fluid is important. If too much fluid intravasates, dilutional electrolyte imbalances can have serious consequences. 4. Ablation is not recommended for patients who wish to preserve fertility. 5. Sample the endometrium before performing an ablation to evaluate for hyperplasia or malignancy. Show Notes Wine pairing: 2017 Nero d’Avola Cabernet Sauvignon from Barone Montalto Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #87 - Published October 2007 (Reaffirmed 2018) 1. Sickle cell trait (heterozygous for the mutation) is generally asymptomatic; sickle cell disease can have severe consequence 2. Sickle cell disorders are more common among individuals of African descent, whereas the thalassemias are more common among individuals of Southeast Asian and Mediterranean descent. 3. Alpha thalassemia results from deletion of any number of the four genes that code for the alpha chain. The more deletions, the worse the presentation. 4. Beta thalassemia results from mutation of one or both of the genes that code for the beta chain. Severity of disease is determined by presence and degree of functionality within intact genes. 5. Sickle cell disease is a risk factor for preterm delivery, IUFD, IUGR, etc., therefore, antepartum fetal surveillance is recommended Show Notes Wine pairing: 2018 Sainte Marie Corbieres from Domaine Faillenc Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Practice Bulletin #225 - Published October 2020 1. Medication abortion is safe and effective (just slightly less effective than uterine evacuation). 2. The standard regimen is mifepristone 200 mg PO followed by misoprostol 800 mcg per vagina 24-48 hrs later 3. Patients who reliably report menstruation within 56 days of presentation for medication abortion do not require ultrasound confirmation 4. Patients at high risk for ectopic pregnancy based your clinical assessment should not be offered medication abortion. 5. Medication abortion has no adverse effect on future fertility or future pregnancy outcomes. Show Notes Wine pairing: 2017 Willamette Valley Pinot Noir from Chemistry Wine Theme music by Evan Handyside Logo design by JD Dotson (jddotson1@gmail.com)

Today we cover medication abortions and review Practice Bulletin 225 that came out this month. We review who is eligible for medication abortion as well as risks, benefits, and other management guidelines.  Please help us out with our survey. We'd love to hear from you: https://redcap.link/creogsovercoffee Twitter: @creogsovercoff1  Instagram: @creogsovercoffee Facebook: www.facebook.com/creogsovercoffee Website: www.creogsovercoffee.com Patreon: www.patreon.com/creogsovercoffee You can find the OBG Project at: www.obgproject.com

Dr. Eva Reina, PGY-3 at Brown, talks to us today about Chronic Pelvic Pain. This is obviously a broad topic, but Dr. Reina guides us through the etiology and work up of pelvic pain. Want to learn even more? Come onto our website or find Practice Bulletin 218. Twitter: @creogsovercoff1  Instagram: @creogsovercoffee Facebook: www.facebook.com/creogsovercoffee Website: www.creogsovercoffee.com Patreon: www.patreon.com/creogsovercoffee You can find the OBG Project at: www.obgproject.com

Practice Bulletin #195 - Published June 2018 Four pearls: 1. Clean your hands, clean the skin, prep the vagina, treat remote infections and keep blood sugars controlled preoperatively to reduce infection rate. 2. Antibiotic prophylaxis is indicated for all hysterectomies, open surgery, and D&C for abortion, but it's generally not indicated in other procedures unless there's risk of entry into the bowel or a communication made between the abdominal cavity and the vagina. 3. Evidence is poor for antibiotic prophylaxis for indwelling foley or suprapubic catheters 4. For patients with penicillin allergy, switch to cephalosporin if allergy is mild, switch to metronidazole (or clindamycin) plus gentamicin (or aztreonam) if allergy is severe or if history of anaphylaxis Shout-outs: - Julie Duhon and Haddie Katz, CPM are looking for an OB to help them open a birth center in Bloomington, IN (email: hellomidwife@gmail.com) SHOW NOTES This episode pairs nicely with the Lot 1 Bonanza Sauvignon by Chuck Wagner Wine. Main theme music by my main amigo, Evan Handyside

Practice Bulletin #216 - Published January 2020 Five pearls: 1. Large babies come with a relatively higher risk to mom and baby, but absolute risks remain low. 2. Shoulder dystocia is generally difficult to. predict, but in diabetic patients with large fetuses, the risk is significantly higher, especially if vacuum or forceps is attempted. 3. Ultrasound is. notoriously inaccurate at predicting fetal weight (+/- 15%), and it's no better than using your hands or asking your patient to guess based on a previous pregnancy. 4. Diet, insulin and exercise are helpful in preventing macrosomia. 5. Inducing labor if fetus found to be macrosomic is not indicated. C-section reasonable if fetus measuring >4500 g in a diabetic patient or >5000 g in a non-diabetic patient Shout-outs: - Maryn Green, CPM (her podcast, on Twitter, Instagram) - Sunita Puri, MD (buy her book on Amazon) SHOW NOTES This episode pairs nicely with the 2014 Restitution Red Wine Blend from Magistrate Wines. Main theme music by my main amigo, Evan Handyside

Practice Bulletin #130 - Published October 2012 (Reaffirmed 2018) Five pearls: 1. Spontaneous preterm birth rates are decreasing with time (woohoo!) 2. Good thing, because PTD at

Practice Bulletin #155 - Published November 2015 (Reaffirmed 2018) Special guest: Ryan Stewart, DO (his 2nd appearance!) Ryan's four pearls: 1. Urinary incontinence is extremely common, but it's not normal. Screening for incontinence is vital for all physicians with female patients. 2. A correct incontinence diagnosis is of utmost importance. Treatment will only work if you know what you're treating. 3. Minimum evaluation for a woman presenting with incontinence: history, urinalysis/= (and maybe culture), physical exam, demonstration of stress incontinence, evaluation of urethral mobility, and post-void residual. 4. Behavioral therapy and pelvic floor exercises improve symptoms of incontinence and may be recommended as first line therapy Shout-outs: - Julie Wiebe, PT on Twitter (and Instagram) - Julie's interview in Ep 35 "Hope for the Pelvic Floor" - Lori Forner, PT on Twitter (and Instagram) - Patagonia makes quality sh*t SHOW NOTES This episode pairs nicely with the 2017 Pinot Noir by Meiomi Wines. Main theme music by my main amigo, Evan Handyside

Practice Bulletin #71 - Published October 2016 Five pearls: 1. Preterm labor carries significant risks to the newborn: the more premature, the worse the outcomes. 2. Given high risk for long-term morbidity in extremely premature infants, focusing on comfort as opposed to aggressive resuscitation at time of delivery is reasonable through a shared medical decision-making process. 3. Corticosteroids can improve outcomes for newborns at risk of preterm birth at

Practice Bulletin #214 - Published November 2019 Special guest: Ryan Stewart, DO (a real life expert in Female Pelvic Medicine and Reconstructive Surgery) We'll cover: - risk factors for POP - diagnosis and classification of POP - conservative management options - pessaries - evaluation for occult stress urinary incontinence before surgical management - the variety of surgeries - the mesh controversy - Nathan and Ryan spend far too long moaning about docusate sodium -...and more! Shout-outs: - Ryan Stewart, DO on Twitter - H Clark Distillery (Tennessee Bourbon) - Things We Do For No Reason: colace blog post - Daring Greatly, by Brene Brown - Brene Brown's Netflix special - Julie Wiebe, pelvic PT SHOW NOTES This episode pairs nicely with the 2017 Russian River Valley from Siduri Winery. Main theme music by my main amigo, Evan Handyside

Practice Bulletin #196 - Published July 2018 We'll cover: - why are pregnant women at higher risk of VTE? - risk factors for VTE in pregnancy - who and how to treat and prevent VTE in pregnancy - what to do for women on thromboprophylaxis who present for delivery - thromboprophylaxis postpartum -...and more! Shout-outs: - The Farm, the greatest place on earth to give birth for many people (my words) - Sara Rosser, midwife at The Farm on Instagram - Ilana Stanger-Ross and her pregnancy book "A is for Advice" SHOW NOTES This episode pairs nicely with the 2017 Tempranillo Viura by Casado Morales Winery. Main theme music by my main amigo, Evan Handyside

Practice Bulletin #174 - Published November 2016 We'll cover: - differential diagnosis of adnexal mass (there's a f*ck ton) - which masses need to be removed - signs of malignancy - when to refer to gyn/oncology - management of masses in adolescents -...and more! Shout-outs: - Augustine Colebrook of the Art of Birthing and her new podcast Worldwide Midwifery - Maryn Green, author of Indie Birth: A Story of Radical Birth and host of the Taking Back Birth Podcast (also on Instagram) - Katya Nova and her podcast Honey Talks (also on Instagram) - Sarah Leahy of Birth Uprising - Ilana Stanger-Ross and her pregnancy book "A is for Advice" SHOW NOTES This episode pairs nicely with the 2016 Educated Guess Cabernet Sauvignon by Roots Run Deep Winery. Main theme music by my main amigo, Evan Handyside

Practice Bulletin #198 - Published September 2018 We'll cover: - female anatomy - characterizing perineal lacerations - associations between vaginal birth trauma and sexual and pelvic floor dysfunction - prevention and management of vaginal and perineal lacerations - postpartum considerations - long-term follow-up - Nathan is clearly a feminist -...and more! Shout-outs: - Ryan Stewart, DO, on Twitter - Thom Knoles interview on the Under the Hood Podcast (Part 1, Part 2) - Maryn Green, author of Indie Birth: A Story of Radical Birth and host of the Taking Back Birth Podcast SHOW NOTES This episode pairs nicely with the 2015 Pinot Noir from Franny Beck Wines. Main theme music by my main amigo, Evan Handyside

Universal thyroid screening in pregnancy is a key debate in endocrinology and obstetrics. While some countries advocate universal screening, the UK and USA adopt a “high-risk” based strategy. ACOG’s Practice Bulletin 148 (April 2015) keeps its recommendation to NOT perform routine screening for thyroid disease in pregnancy. BUT, should we screen for thyroid abnormalities universally? This podcast will review the pros and cons and make a push for once stance over the other.

Practice Bulletin #197 - Published July 2018 We'll cover: - review of the clotting cascade - physiologic changes in pregnancy that affect clotting - VTE risk in and out of pregnancy - pathophysiology of inherited thrombophilias - criteria for starting thromboprophylaxis in pregnancy - Nathan's #1 fan made him new theme music -...and more! Shout-outs: - Augustine Colebrook, CPM, founder of Wise Women Education and host of Worldwide Midwifery (her Instagram page also rocks) - Nicole Nolan, MD, on Twitter - Taking Back Birth podcast - The Infertility Cure by Randine Lewis, PhD - Guest theme music by Jake Curtis (@orangegemini on instagram) SHOW NOTES This episode pairs nicely with the 2015 Tempranilla from Las Almenas. Main theme music still by my main amigo, Evan Handyside

Practice Bulletin #199 - Published September 2018 We'll cover: - evidence skin/vaginal prep before c-section - selecting the correct agent and dose - PPROM antibiotic regimens - are antibiotics necessary for preterm labor, cerclage, or manual extraction of placenta - Nathan bores you with Burning Man stories (...or does he?!) -...and more! Shout-outs: - Mountains Beyond Mountains, book by Tracy Kidder - Daniel Ginn, DO, on Twitter - Ryan Stewart, DO, on Twitter - Jeffrey Sperling, MD, on Twitter SHOW NOTES This episode pairs nicely with the 2018 Pinot Noir by Cono Sur. Theme music by my main amigo, Evan Handyside

Practice Bulletin #200 - Published November 2018 We'll cover: - diagnosis of early pregnancy loss - risks/benefits of expectant, medical and surgical management - Nathan gets tipsy ...and much more! SHOW NOTES This episode pairs nicely with the Anew Pinot Grigio (in a can!). Theme music by my main amigo, Evan Handyside

Practice Bulletin #213 - Published July 2019 We'll cover: - classification and diagnosis of female sexual dysfunction - pregnancy-related and menopause-related sexual dysfunction - estrogen and other medications that may be helpful - psychologic and other non-pharmacologic interventions - Nathan gets back up on his soapbox ...and much more! SHOW NOTES This episode pairs nicely with the 2017 Chardonnay from Chloe Wine. Theme music by my main amigo, Evan Handyside

Practice Bulletin #251, Published in January 2020 We'll cover: - understanding normal vaginal pH and flora - role of estrogen in maintaining vaginal health - infectious and non-infectious causes of vaginitis - diagnosis and treatment of candidiasis, bacterial vaginosis, and trichomoniasis ...and much more! SHOW NOTES This episode pairs nicely with the 2016 Pinot Noir from Carmel Road Winery Theme music by my main amigo, Evan Handyside

Practice Bulletin #212 PART 2 OF 2 - Pregnancy and Heart Disease, Published April 2019 We'll cover: - identification, assessment, and management of patients at high risk of peripartum cardiomyopathy - acute coronary syndrome and myocardial infarction in pregnancy - management of cardiac arrest in pregnancy, including perimortem cesarean delivery and resuscitative hysterotomy - antepartum, intrapartum, and postpartum management of patients with CVD ...and much more! SHOW NOTES This episode pairs nicely with the Criminal 2017 Red Blend from Truett Hurst Winery Theme music by my main amigo, Evan Handyside

Practice Bulletin #212 PART 1 OF 2 - Pregnancy and Heart Disease, Published April 2019 We'll cover: - risk stratification of cardiovascular disease (CVD) in pregnancy - prenatal counseling and workup - workup of new-onset symptoms concerning for worsening or new-onset CVD in pregnancy ...and much more! SHOW NOTES This episode pairs nicely with the Pacific Redwoods Organic Red from Frey Vineyards Theme music by my main amigo, Evan Handyside

Practice Bulletin #211 - Critical Care in Pregnancy, Published April 2019 We'll cover: - indications for ICU consult - why asking for help doesn't make you a sissy - physiologic changes in pregnancy - ICU mortality data for pregnant women - ARDS and sepsis - coding a pregnant woman - mechanical ventilation considerations ...and much more! SHOW NOTES This episode pairs nicely with the E-6 Spanish Blend from Locations Wine Theme music by my main amigo, Evan Handyside

Practice Bulletin #203 (Part 2 of 2) - Chronic Hypertension in Pregnancy, Published December 2018 . We'll cover: - guidelines for treatment of chronic hypertension in pregnancy - management of severe hypertension in pregnancy - other intrapartum and postpartum considerations ...and much more! SHOW NOTES This episode pairs nicely with the 2018 Malbec from Öko Winery Theme music by my main amigo, Evan Handyside

Practice Bulletin #203 - Risks and Benefits of Sterilization, Published December 2018 We'll cover: - definitions and diagnosis - first prenatal visit - maternal and fetal risks - things to watch for throughout pregnancy - superimposed preeclampsia ...and much more! SHOW NOTES This episode pairs nicely with the 2016 Old Vine Zinfandel from Four Vines Winery Theme music by my main amigo, Evan Handyside

Practice Bulletin #208 - Risks and Benefits of Sterilization, Published January 2019 We'll cover: - counseling and alternatives - male and female sterilization - safety and efficacy of various techniques ...and much more! SHOW NOTES This episode pairs nicely with the 2016 Red Blend from Rabble Wine Company Theme music by my main amigo, Evan Handyside

Practice Bulletin #207 - Thrombocytopenia in Pregnancy, Published March 2019 We'll cover: - etiologies - work-up - management ...and much more! SHOW NOTES This episode pairs nicely with the 2016 Reserva Malbec from Bodega Norton Theme music by my main amigo, Evan Handyside

Practice Bulletin #210 - Fecal Incontinence, Published April 2019 We'll cover: - epidemiology - risk factors - evaluation - medical and surgical treatment options ...and much more! SHOW NOTES This episode pairs nicely with the Penfolds Koonunga Hill 2016 Shiraz Cabernet Theme music by my main amigo, Evan Handyside

Practice Bulletin #209 - Obstetric Analgesia and Anesthesia, Published March 2019 We'll cover: - opioids - epidural/spinal anesthesia - pudendal nerve block - nitrous oxide - general anesthesia - risks to mother/fetus - contraindications - anesthesia and breastfeeding - post-cesarean delivery pain management - neuraxial precautions with anticoagulation SHOW NOTES This episode pairs nicely with the 2016 Seven Oaks Cabernet Sauvignon from J. Lohr Vineyards and Wines Theme music by my main amigo, Evan Handyside

Practice Bulletin #205, Vaginal Birth After Cesarean Delivery, Published January 2019 We'll cover: - epidemiology - risk and benefits counseling for patients - diagnosis and management of uterine rupture - risks to future pregnancies - management of TOLAC ...and much more! SHOW NOTES This episode pairs nicely with the 2016 Apothic Crush Smooth Red Blend Theme music by my main amigo, Evan Handyside

Practice Bulletin #202 (Part 2 of 2) - Gestational Hypertension and Preeclampsia, Published January 2019 We'll cover: - intrapartum management of severe preeclampsia - magnesium toxicity - management of acute hypertension - management of eclamptic seizures - postpartum considerations - special consideration in HELLP syndrome - long-term consequences ...and much more! SHOW NOTES Part 2 pairs nicely with the 2017 Unoaked Tempranillo from El Jefe. Yes...I had to consume two bottles of wine for this recording...aren't you nosy. Theme music by my main amigo, Evan Handyside

Practice Bulletin #202 (Part 1 of 2), Gestational Hypertension and Preeclampsia, Published January 2019 We'll cover: - epidemiology - risk factors - prevention - diagnosis - maternal and fetal consequences - inpatient versus outpatient monitoring - expectant management versus delivery - pathophysiology - associated conditions (e.g. HELLP, PRES, eclampsia, etc.) ...and much more! SHOW NOTES This episode pairs nicely with the 2015 Lagrein Riserva from Glassier. Theme music by my main amigo, Evan Handyside

Recent recommendations from the American College of Cardiology (ACC) and the American Heart Association (AHA) have changed the criteria for diagnosing hypertension in adults. In January 2019, the ACOG will release Practice Bulletin #203 addressing these changes, and provide renewed guidance for management of chronic hypertension in pregnancy. This is PART 1, of a 2-Part review of PB#203.

Practice Bulletin #201, Pre-gestational Diabetes Mellitus, Published December 2018 This episode is packed. We'll cover: - epidemiology - diagnosis - patient follow-up and home glucose monitoring - serum glucose goals prenatally and intrapartum - how to prescribe insulin or oral antihyperglycemics - management of nocturnal hypoglycemia - risk of poor glucose control to mom, fetus, and newborn - timing and mode of delivery - postpartum considerations ...and much more! SHOW NOTES This episode pairs nicely with the 2015 Old Vine Zinfandel from Brazin Cellars Theme music by my main amigo, Evan Handyside

Practice Bulletin #194, Polycystic Ovarian Syndrome, Published June 2018 We'll cover: - diagnosis and clinical workup - etiology - review of metabolic syndrome - clinical manifestations of PCOS - differential diagnosis - associated co-morbidities and risks - use of COCs to treat metabolic derangements and menstrual disorders - ovulation induction and other management options for infertility in PCOS ...and much more! SHOW NOTES This episode pairs nicely with the 2016 Wintner’s Collection Merlot from Sterling Vineyards Theme music by my main amigo, Evan Handyside

Practice Bulletin #193, Tubal Ectopic Pregnancy, Published March 2018 We'll cover: - epidemiology - risk factors - interpretation of serial ultrasounds and serum bHCG values - follow-up for pregnancy of unknown location - risks and benefits counseling for your patient when things aren't so black and white - to aspirate or not to aspirate the uterine cavity - medical versus procedural management of ectopic - ins and outs of methotrexate ...and much more! SHOW NOTES This episode pairs nicely with the 2016 667 Pinot Noir from Noble Vines Theme music by my main amigo, Evan Handyside

Practice Bulletin #161 External Cephalic Version and Committee Opinion #340 Term Singleton Vaginal Breech Delivery

Practice Bulletin #165 Prevention and Management of Obstetrical Lacerations at Delivery

Guest: David Stone, MD Host: Ana Maria Rosario It's been two years since ACOG released Practice Bulletin #130 regarding the Prediction and Prevention of Preterm Birth. Where are we today in identifying patients who are a great risk? How can clinicians put the information into clinical practice to provide significant outcomes? Senior reporter Ana Maria Rosario welcomes Dr. David Stone, Practicing Ob-Gyn in the metro Detroit area for over 20 years. Dr. Stone shares his clinical experience, perspective and passion regarding the every day practice of predicting and peventing preterm birth. Dr. Stone is a Fellow of the American College of Obstetrics and Gynecology and a member of several national organizations including the American Medical Association and the Society of Robotic Surgeons