Archived User


Hello Henci!

I have a couple of questions for you about my upcoming VBAC delivery.  First of all let me give you a little bit of my background.  I am currently 35 weeks pregnant with my 5th child.  My first 2 were delivered vaginally at just over 39 weeks.  My first was started when my water broke on it's own.  After 12 hours of labor (without an epidural) and not much progression they decided to give me pitocin to help it along.  At that time I asked for an epidural as I was very tired after laboring all night without any sleep.  My son was born about 5 hours after I got my epidural.  My second child was a scheduled induction after 2 days of inconsistent but constant contractions.  When I was checked right after they started the pitocin I was already dilated to a 4 and was told I would have probably been in later that day to have the baby even without the induction.  That labor lasted a total of 5 hours and I had an epidural.  My 3rd child was born by emergency c section.  My water broke and 4 hours later I was at a 9 1/2 but the baby's heartbeat was going down in between contractions.  My doctor tried to finish stretching me but it didn't work.  After being prepped for surgery my doctor again tried to stretch me in the OR but again it didn't work.  After the baby was born we found that his cord was wrapped around his neck 3 times and the doctor figures it was hanging him in between contractions and not letting him descend enough to finish dilating.  With my 4th child I was going to try a VBAC but due to unforeseen circumstances we ended up moving across the country when I was 37 weeks pregnant.  My previous doctor (the one that delivered #2 and 3) would not attempt a VBAC since his office was at one hospital and my insurance would only cover the hospital that was across town (about 5 miles away).  At that point I had been through enough emotionally and didn't feel I could find a completely new doctor and just decided to do a scheduled c-section.  
I have been fortunate to find a doctor with this baby that is willing and very supportive to try a VBAC.  My question is this:  my doctor has told me that I should definitely have an epidural since there is an increased chance of emergency c-section if there was a rupture.  My research tells me that the epidural might cause more of a chance of having to do a repeat c-section.  So which is it?  Should I or should I not have an epidural?  If it is better to not have an epidural can you tell me of some articles or research to back that claim that I can show to my OB?  Also, my doctor says I will have to go into labor on my own (consistent with my research) but that if we need pitocin to help me along we could use it after active labor has started.  What are your thoughts on that?  Lastly, I have never used a doula but believe it would be advantageous if I don't get an epidural.  How would I go about finding one at this point of pregnancy and how much would I expect to pay (I live in Northern Utah)?   Thanks ahead of time for your help!

Henci Goer

(in response to Archived User)

I am not aware of any research that supports or guidelines that recommend having an epidural in place for a VBAC. You may wish to ask your doctor for the evidence supporting this practice because you are right that epidurals slow labor, increase the need for oxytocin to augment labor, and interfere with pushing. In addition, one of its side-effects is an episode of slow fetal heart rate either secondary to a drop in maternal blood pressure, the most common adverse effect of epidurals, or just on its own. This could lead to a false-positive diagnosis of scar rupture because a slowing of fetal heart rate is its most reliable symptom. I would add, too, that your prior vaginal births greatly increase the odds of having an uneventful labor ending in vaginal birth. That being said, if you like everything else about your doctor or you have no other choice, you may wish to compromise on having the epidural set but not running any anesthetic through it.

Your ob is right to be leery of inducing labor as it reduces the likelihood of vaginal birth. However its association with scar rupture has to do with whether the woman was induced with an unripe cervix, whether cervical ripening agents were used--cervical ripening agents soften connective tissue in the cervix, but the scar is also connective tissue--and possibly both. You had better find out, though, if your ob is willing to wait for your labor to start on its own or whether your ob will insist on an elective cesarean if, say, you still haven't gone into labor by a certain date or the doctor thinks the baby will weigh more than a certain amount. If that is the case, you will have to see whether your ob will honor your right to informed refusal or find someone else.

So far as using oxytocin to induce or augment labor, not all studies find this problematic for the scar, but others do. I'm willing to bet that the reason for the difference is that in the ones that didn't,  induction was only undertaken in women whose bodies were ready to labor and a physiologic oxytocin dosing protocol was used for inducing or augmenting labor. You may wish to ask your ob whether he or she uses an active management (high-dose/short-interval between dose increases) regimen or a physiologic regimen. (FYI: The recommended oxytocin dosing regimen is in the Pitocin package insert.)

I strongly recommend hiring a doula. The largest of the doula organizations is DONA International. The link will take you to DONA's home page. Look at the left of the page, and you will see a drop down menu to locate a doula. You will also find some good general info on doulas, including how to hire one.

~ Henci

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