I don't know if she would have had a vaginal birth had she agreed to labor augmentation, and some studies have found that it increase s the likelihood of scar rupture, although not by a large amount. (See below: one large study reported a rate of 4 per 1000 with spontaneous labor and 9 per 1000 when oxytocin is given to strengthen contractions.) It sounds like she had the same problem she had the first time: a malpositioned baby. So last time she had an epidural and IV oxytocin (Pitocin is the brand name in the U.S.) and had a c/sec. This time she tried no epidural, patience, and everything you and she could think of to coax the baby into a more favorable position, and that didn't work either. Frankly, it seems unlikely to me that more time or an epidural plus augmentation would have made a difference since that strategy didn't work the first time. In the long run, she was destined to have another cesarean. I think the key issue is how your client felt about the decision making process.  

As for the nonreassuring fetal heart rate pattern, it is true that abnormal patterns have a weak relationship with newborn outcomes and that there may be other reasons for some of them besides distress. Nonetheless, you have a situation where no progress has been seen for hours in a woman in active phase labor despite efforts to resolve the difficulty, and the baby's heart rate pattern is now less than optimal. Proceeding to a cesarean certainly seems a reasonable thing to do although it may have been possible to wait longer, which takes us back to how your client feels about the decision being the critical issue. I will add, too, that this obstetrician may have been using the term "emergency" in a different sense than we commonly think of it. Studies I have read not infrequently use the term "emergency" cesarean simply to mean "a cesarean during labor," as opposed to a scheduled cesarean, without regard to urgency. It is possible the obstetrician was using it in this sense.

-- Henci

Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351(25):2581-9.

Catherine:

When I deleted your accidental post, it took the whole thread with it, including your completed post. Fortunately, the post had been sent to my e-mail, and it was short enough that it was included in its entirety. I have copied it in here. I'll respond to it later today when I have more time.

Henci

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Subject: RE: Reasons for stalled labour

My apology for hitting the submit button accidentally;P

I am a doula and supported an attempted VBAC. Mum had a hind water leak and contractions followed. After checking into the hospital, she was only 3 cm dilated.She only reached 5cm after 10 hours. The proposal to augment labour was brought up but mum refused for fear of fetal distress and uterine rupture. She was still  coping well physically; nibbling and drinking . She decided to wait.  She remained the same after another 7 hours. Throughout, she was mobile, adopting various postions like squating , lunging, on her fours and laboured in the tub, walking etc. No intervention  was done except for the 4 hourly,  30 minute  EFM.  The OB suggested an emergency C-section  after a vaginal exam and mentioned that the baby's head was still high and the cervix was swollen. Another concern was the trace on the EFM showed no 'beat to beat variability" .

Previously for her first labour, the mum also stalled at 6cm but had epidural and synto. when she was 4 cm.Her waters released on its own. Baby was posterior and  asynclitic.

My question is,

Could she have a successful VBAC if she had consented to an augmentation with epidural at 5 cm earlier?

Could she be given more time since there was no intervention done to her?

Is a swollen cervix an indicator of uterine rupture, a reason for emergency C section?  Or CPD?

From what I understand from the book, " HOME BIRTH BOUND"  by Maggie Banks, for  30% of the time, between 36-42weeks gestation, the unborn baby will be in quiet state and there will be very little variation in his heart rate pattern and no rapid eye movement. So could the trace be a  false ' positive'?

Thanks,

Catherine