"Mandatory epidural" for a VBAC?

[kungfumoose]

I'm currently 36 weeks along. I'm having a trial of labor for a VBA2C.
At my last appt. the OB said that they expect me to get an epidural at 4-5cm.
I'm okay with this, but I wondered if that will lower my chances of a successful vaginal delivery.
The OB said that if I have the epidural, and there is a catastrophic rupture, they can immediately section me, by putting the spinal block right in the epidural, avoiding a general anesthetic, and all the complications that come from that. It makes sense, to have faster access to a section if needed.
I've had two long natural labors (the last was 77 hours of active labor) that ended with a section anyway, and I'm happy about the idea of less pain.

I just don't want to lower my chances of success.
Has anyone heard of this before?
Do you know if it would lower my chances of success?

[katelove]

Yes, I have heard of this before but only on-line. I haven't seen it in practice anywhere that I have worked (Australia does differ quite a bit from the US though).

Here is the link to a summary of the cochrane review of epidural use in labour. As you can see they have not found that the overall c/s risk is increased with an epidural, although the chance of most other interventions is increased.

Remember that this is only your OBs recommendation. It is not the law. You can decline if you want to. Or decline at 4cm and wait until later. Ultimately it's up to you what you feel comfortable with.

[roadfamily6now]

Well, it is true that the risks of additional interventions rise with the use of an epidural which in turn will increase your risks of having another c-section but at the same time, some women can get an epidural and finally be able to relax and have a baby vaginally.

However, it is ALWAYS your choice to have one or not despite what anyone says.  If there is a true emergency, they will put you out and skip the epidural all together.

[CordeliaLynn]

Remember that your body (pelvis) was designed to widen (up to 30%) during labor......but that this is physically impossible to do if you are laying flat on your back.  You need to be standing, kneeling, squatting, etc...  So if your pelvis is not currently wide enough to fit a baby through, then definitely refuse the epidural.  If the doctors need to do an emergency c-section, they can give you general anesthesia.  Just my 2 cents!  Good luck!!

[sha1212]

I just had a VBAC 10 days ago (one prior cesarean). I was not told this about the epidural. In fact, I had hoped to forgo the epidural altogether because I was concerned, like you are, that it would lessen my chances (I was also diagnosed with a cardiovascular issue this pregnancy which results in drops in blood pressure, so I was worried the epidural would affect me negatively). A friend whose husband is an anesthesiologist asked him about whether I'd need one beforehand, and at first he said, oh yes, we want VBAC patients to have them, but when I pressed she said he agreed it was really because they'd rather you have it than have to be on hand to do it quickly.

Anyway, in the end I did get an epidural because I requested it, but not until 10 cm with a slight lip. I believe a big part of why I had the first c/s was because I got the epidural too early (4 cm) so I'm glad I avoided that this time. But maybe your doctor's recommendation has to do with the slightly higher risk of rupture since you've had two c-sections, or is just their policy???? FWIW, I switched practices at 36.5 weeks when I realized my OB was supportive of VBAC in theory but not really in practice. I switched to the midwife practice at the large university medical center in my city, and my baby was delivered by the midwife with an OB standing by in case I needed a c/s. They were so much less intervention-happy at this hospital and really supported my need to switch positions, let my body do its thing, etc. I'm pretty sure I would have had a repeat c/s at my old hospital after the OB decided I'd taken up enough of her time. Maybe you could see if there's another place you can deliver that has a higher VBAC rate or a more supportive approach to it?

 

[Blue Eyed Baby]

It is generally best to wait until 5-6cm because then baby is usually in proper position. If you get the epi too early it increases your risk due to many different factors. One being if you have an Epi too early and your babiy is OP the baby may not turn, and if you can't push out an OP baby guess how he/she is coming out. Also once you're given an epi, even a "Walking" epi any hospitals will not allow you to get up and move around due to liability issues, and trust me it helps to walk and be able to change position on your own.

 

Originally Posted by kungfumoose 

I'm currently 36 weeks along. I'm having a trial of labor for a VBA2C.
At my last appt. the OB said that they expect me to get an epidural at 4-5cm.
I'm okay with this, but I wondered if that will lower my chances of a successful vaginal delivery.
The OB said that if I have the epidural, and there is a catastrophic rupture, they can immediately section me, by putting the spinal block right in the epidural, avoiding a general anesthetic, and all the complications that come from that. It makes sense, to have faster access to a section if needed.
I've had two long natural labors (the last was 77 hours of active labor) that ended with a section anyway, and I'm happy about the idea of less pain.
I just don't want to lower my chances of success.
Has anyone heard of this before?
Do you know if it would lower my chances of success?

[JaimeF]

Oh dear, you do not need an epidural and should not have one.  It will increase your chances of another c-s.  Do you have a doula?  it is not too late if not.  They can make all the differnce.  You can do this and you have rights and they can not force you to have one.  Our bodies are amazing and can produce pain killers on their own if we let them by staying relaxed and putting into practice the comfort measures we learn about during pregnancy.  I have a vbac group on facebook you are more then welcome to join.  There are tons of resources and videos and such lists of comfort measure and so on.  https://www.facebook.com/groups/183444955077965/

[justKate]

Hey OP, one of the OBs at my hospital told me the same thing.  I do think it would lower my chance of a successful VBAC, and I told her I would not be getting an epidural unless I feel that i need it for pain.  If you don't have a doula, definitely get one.  There's time!

[Haelmoon]

I don't think and epidural is necessary for a VBAC. Most epidurals take 20 minutes to "top-up". A spinal can be placed by an experienced aneasethiologist in less time and be just as or even more effective. I understand the goal of avoiding a general anasethic, but any truly emergent c-sections I have been involved with required a general anyways because we weren't going to wait for the epidural to be effective. If you have a rupture requiring and emergent surgery because you or the baby are unstable, ou would get a general anyways. If not, and the section is for another less urgent indication, they can still give a spinal anasethic.

My first was a c-section at 32 weeks because I had ruptured my membranes and prolapsed her cord. I had a spinal because the doc on for the day said he could do it as fast as a general, and then I would know that my baby was fine faster (not waiting until I woke up later). It wasn't the most effective spinal, but I remember her being born and making noise. Then he snowed me because it was a little uncomfortable, but I knew she was fine. I had an epidural for my first VBAC (persistanct OP at 34 weeks, head low with an urge to push but only 4 cm for hours) and nothing with my third (breech VBAC). No hospital policies where I delivered.

[VBACmama4]

I had an epidural during my first birth experience which was really only part of a slippery slide of interventions that ultimately led to an unnecessary C/S. The epidural totally stalled my labor, as did the flat on my back position I had to stay in after it was administered, giving my doctor the perfect situation to start pressuring about "failure to progress". I was young, I agreed, and it was a huge mistake. BUT, I do know women who have had an epidural and swear by it, even during VBAC. I personally avoid them like the plague because of the way my body reacted to the first one, and I've had 2, soon 3, successful VBAC's. If you have a really low tolerance for pain you might want to indicate in your birth plan that you're open to meds, but I wouldn't let them schedule an epi because believe me, they will stick to those plans no matter how you feel at the time. I second the recommendation for a doula as well if you are questioning their tactics at all, because that person is trained to be a solid presence while you are vulnerable and unsure. I'd also avoid allowing the hospital to give you meds to speed thing up, because not only does that cause a much more intense and painful labor but it also increases the risk of rupture. 

GOOD LUCK!!!

[tonttu]

Are you sure , that the doctor´s recommendation for an epidural is not his sneaky way of hoping , that you will end up with another cs ?

Getting one at 3-4 cm is still quite early and you might still have a long way to go . 

And having an epidural for a longer time , will definitely increase the risk for fetal heart problems . 

Plus , I had a partial rupture in my VBA1C and they will not waste time " topping " it up , that is bogus , it takes time for that to work and if there is a REAL emergency , you will be put under GA .

It makes me so mad , when doctors act like epis , who are so dangerous and have so many risks involved , are being portrayed as a harmless way to get you out of pain .

Even if things are going well , there have been many different studies done , that all conclude , many other interventions , that come along with epis not only greatly increase risk of cs in general , but those also greatly increase the rupture risk .

And , sorry , but any anaesthesiologist telling you , that he can do a spinal as fast as a GA , is either horribly slow at doing te GA , which takes moments to take effect ( unlike a spinal ) or whoever he gave such a quick spinal to , was incredibly lucky , they didn´t end up with some serious problems afterwards .

Sounds to me , like they are simply trying to fool you into another cs 

[holly6737]

An epidural does not increase your chances of having a c/s if you're in active labor when you have an epidural. It increases your risk of a persistently OP baby, but not a c/s. Most providers know when you get an epidural that it may take you longer to get the hang of pushing, etc.  In midwifery school, I was taught to allow an additional hour of pushing for women with an epidural before discussing operative delivery.

That said, you shouldn't have to get an epidural if you dont' want one. Now, you may decide that you do want one and that's okay. But if you decide you don't want one, I would just tell him, "I understand the risks of general anesthesia in the event that I have a catastrophic rupture and I accept those risks. I am choosing to forego the epidural." Maybe he'll be okay with that, maybe he won't. If he's not, then I'd rather find another doctor than fight with him on it, kwim?

[roadfamily6now]

Originally Posted by holly6737 

An epidural does not increase your chances of having a c/s if you're in active labor when you have an epidural. It increases your risk of a persistently OP baby, but not a c/s. Most providers know when you get an epidural that it may take you longer to get the hang of pushing, etc.  In midwifery school, I was taught to allow an additional hour of pushing for women with an epidural before discussing operative delivery.

That said, you shouldn't have to get an epidural if you dont' want one. Now, you may decide that you do want one and that's okay. But if you decide you don't want one, I would just tell him, "I understand the risks of general anesthesia in the event that I have a catastrophic rupture and I accept those risks. I am choosing to forego the epidural." Maybe he'll be okay with that, maybe he won't. If he's not, then I'd rather find another doctor than fight with him on it, kwim?

Do you happen to have a link or research for that?

[justKate]

OP, any updates?

FWIW, I think the OB who suggested to me that "they" prefer VBACers to have an epidural in place was one of those overly cautious types--not so much that she loved epidurals but that she wasn't fond of delivering babies under general anesthesia.  She kept going over how the baby would receive the anesthesia, too, stuff like that.... DH and each of his sisters were born under general anesthesia in the '60's and '70's, so its hard for me to believe that its all that much more dangerous that the potential consequences of the epi or of a ERCS after a TOL.  Sorry, not buying that its a necessary. AFM, I'm agreeing to a hep-lock but nothing else from the outset.

[VBACmama4]

Holly, even though Epis aren't statistically linked to a higher occurrence of C/S in two studies of women who received them in active labor, there are well known correlations of complications that can be attributed to Epis. Specifically, inability to change position, a higher risk of mechanically enhanced births (forceps, vacuum extraction), and in my case and the case of many other women, labor being totally stalled after receiving the Epi. I was in active labor when I was coerced into an Epi to "ease the pain" of induction but instead it halted all progress, and I know many other women who had the same or similar experiences. Many of the women I've talked to about this very topic were rushed to reach the pushing stage once the "Epi clock" started ticking, which is one cause of the high rate of C/S's due to "failure to progress" - as though 'taking too long' means a woman won't be able to deliver her baby at all.

My point wasn't that there is a higher risk of C/S with Epi but that many of the persuasive tactics used, including OB's using fear to gain the upper hand, can result in an unnecessary C/S especially in a woman in whom they've already instilled fear of failure. It strikes me as a huge red flag that her doctor is already pushing meds before even allowing her time to start labor and determine her pain tolerance or ability to labor on her own, it seems to me like her doctor is already anticipating needing to intervene before her labor even begins. 

[babycatcher12]

I worked with an OB who would have his VBACs have an epidural placed, but not put medication through it unless they wanted to. That way they had access should it become necessary, but if she wanted a med free labor she could have one. 

[2ndPrincess]

I have read that the way to get the best results it's to have no medical intervention and to be able to be very mobile and even get into different positions for pushing. With you having had 2c-sections already you would want to increase your odds as much as possible. But then again you have to worry about your chances of having a uterine rupture are higher then someone who has just had one c-section. But even then your percentage of having a UR is less then 1%. So that is still pretty low. I am very worried though about the same thing, not getting an epidural and needing to go in for surgery and being able to feel everything. I talked to my doctor about this, and he said there wasn't anything to worry about and he would be able to get some medication in me in time. Your doctor wants you to have for the worst case scenario and that is to go into immediate surgery. I think your chances of needing to go into surgery right away would be lower then your labor just isn't progressing and they just decide to do a c-section, which would give you enough time to get a spinal or epidural in time. Maybe you could come to a compromise like instead of getting the epidural at 5cm get one at 7. I had an epidural at 5cm and it stopped my labor so I had to get a c-section. 

[2ndPrincess]

I have read that the way to get the best results it's to have no medical intervention and to be able to be very mobile and even get into different positions for pushing. With you having had 2c-sections already you would want to increase your odds as much as possible. But then again you have to worry about your chances of having a uterine rupture are higher then someone who has just had one c-section. But even then your percentage of having a UR is less then 1%. So that is still pretty low. I am very worried though about the same thing, not getting an epidural and needing to go in for surgery and being able to feel everything. I talked to my doctor about this, and he said there wasn't anything to worry about and he would be able to get some medication in me in time. Your doctor wants you to have for the worst case scenario and that is to go into immediate surgery. I think your chances of needing to go into surgery right away would be lower then your labor just isn't progressing and they just decide to do a c-section, which would give you enough time to get a spinal or epidural in time. Maybe you could come to a compromise like instead of getting the epidural at 5cm get one at 7. I had an epidural at 5cm and it stopped my labor so I had to get a c-section. 

[tonttu]

For anyone , who is interested , and I assume most of you are , there was a study published by the British journal of obstetrics and medicine in April of 2010 , that not only stated , that the risk of VBAC after even multiple cs was very small , but that the risk after more than one cs was not bigger than after just one . 

Very interesting read ! 

It pops up , if you google " VBAC may be possible after multiple cs " 

It also stated , that there were more incidents with ruptures with women after 2 cs , that women after 3 , which seemed puzzling at first , but then the researchers realized , that the main reason was probably , that doctors were a lot more careful with giving women after 3 cs medication , such as pitocin or similar drugs and therefore it showed quite clearly , that the more medical intervention , the higher the chance of rupture .