VBAC
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Opinions on Epidurals
in VBAC
Do you think having one decreases your odds of having a successful vbac? I am trying to write a birth plan (I didn't have one last time.) And am interested in your opinions (those who've had vbacs or not.)
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Re: Opinions on Epidurals
This is a tough question to answer. There is scientific evidence that getting an epidural before active labor significantly increases your risk of having a c/s. Whether it increases that risk once you are in active labor is not so clear. I haven't seen any studies showing a definite association between epidural anesthesia (EA) and c/s if the epi is done after active labor has begun. If anyone knows of any, please share them.
There are studies finding correlations between EA and fetal malposition. There are a bunch of us here, like me, who had their primary c/s for a malposition. Even if the epidural didn't cause the malposition, that correlation is enough to make me want to stay away from them for my VBAC.
Then there is the issue that EA limits the number of positions you can labor and push in. Many people believe that being active in labor and trying different pushing positions can make a huge difference in a vaginal delivery or a c/s for FTP/FTD. Many people also believe that EA can slow or stop labor altogether, making Pitocin necessary. Pit doesn't always work, or it can cause fetal distress, and in a VBAC it may also increase the risk of UR--all of these could also lead to another cesarean. EA can also make it harder for you to push, so if you ran into issues during the pushing phase, you might want to avoid EA for a VBAC.
So for me, those are enough reasons to try and avoid an epidural for a VBAC. But I think choosing an epidural for a VBAC is also very reasonable. It certainly does not doom you to a repeat c/s, and in the event of an emergency repeat, it may be the difference between being awake for your surgery or being put under. Many people have smooth vaginal deliveries with EA, including VBACs.
I agree with everything iris said, but especially the issue of movement and positioning. Iris, in the research you mentioned was fetal malpositioning determined at time of birth or at some other point during labor? What I mean is, could there have been malpositioned babies who were more effectively rotated by the mothers without epidurals.
For me, the entire setting is of concern. If I were sure to be bed-bound, on my back, with continuous monitoring, it would be easier for me to choose an epidural. For one, I know that labor pain is easier for me to manage when I can move around and take a shower. Plus, I think the odds of malpositioning are higher without the ability to move around.
I would look at the whole setup and what restrictions you might have. Many hospitals require continuous monitoring for all patients, especially for VBACs. Can you walk around (wireless monitors)? Can you try different positions for pushing? Will you be given Pitocin? I can't imagine enduring labor induction or augmentation without pain relief!
I agree with Iris. I don't think an epi in and of itself decreases the odds of a successful VBAC, but I do think it can often lead to other things that do increase the odds of a c/s. (like imobility, Pitocin, etc).
I was pretty set on no epi for my VBAC, mostly becuase I didn't feel comfortable with the adding the risks it brings with it. I also didn't want to not be able to feel my body. If my uterus was rupturing, I wanted to know about it and I felt like if I was numb, I wouldn't notice a difference in contractions and u/r.
I don't think epidurals are bad, but it just wasn't for me.
I haven't done all the research the previous posters have about epidurals and positioning, c-section rates but I have had a successful VBAC. My first c-section was for breech, but my baby was breech from 20 weeks on, not during labor.
Second baby I knew I wanted a VBAC but I'm not brave enough to go natural. My water broke at 7am and I went right to the hospital and got a GREAT epidural. I slept from 10am until 1:30pm when they woke me up because the baby was having decels on monitoring. When they checked me I was crowning! In ten to fifteen minutes of pushing he was out. The only bad part was I was so numb it was hard to tell if I was pushing effectively.
I have so much respect for women able to go med free but it is not for me. Especially since I had an IUPC for continuous monitoring which limited movement and position changes for comfort. I still feel pretty lucky overall that the hospital and staff were supportive of VBAC at delivery. I've heard so many stories about it being discouraged.
I'm going to tell you right now I didn't read any of the PPs. IMO, it can. IMO, it also has a place. Every intervention has a time and place. The problem with interventions is not the actual intervention, but the improper use of them. Recently, on my hypnobabies yahoogroup a mom posted her birth story. She had such violent vomiting with her contractions that she was unable to cope, and after 30 hours got an epidural. In her case, that was proper use of an intervention and she was able to control herself enough to have a vaginal delivery. But walking into a hospital with no options for coping and no training in what those options are and asking for an epi as soon as you qualify for one - THAT is misuse of technology that leads to the cascade of interventions.
I can also tell you that my epidural was the single worst experience of my entire labor and birth. Aside from the emotions that went with getting an epidural, it hurt to get it, I don't like to be numb, and I felt completely disconnected from the entire event anymore. Granted, I got mine 1 hour before my CS when I was told you get one and sleep, and if you don't progress in an hour we're cutting you. So I pretty much knew it was over. But you get the idea.
I'll just quickly tell you my story.
I tried to labor for as long as possible without the epi. My water broke and I was having contractions. But they were irregular and I wasn't making much progress. So after 4 or 5 hours I had to have pitocin, which limited me to being in bed. I labored (with coaching from my doula and DH) well for another 4 or 5 hours, but only progressed 1 or 2 cm. I was tired and knew there was no way I was going to have any energy to push if I had to keep laboring like that for another 13-15 hours. I chose to get the epi so I could get some rest.
It turns out that I was way too tense. The epidural allowed my body to relax and I progressed from 4cm to 10cm in under 2 hours. When I said I thought I needed to push, no one believed me, but I was. 10 minutes later my son was out.
Everyone's experience is different and I'm very glad that I tried to labor naturally, but the epidural was a great decision for my labor.
And FWIW, I didn't have an epidural with my DD and had to have my emergency c-section under general anesthesia.
OK I'm looking back through some of the studies I've seen. I can only access the abstracts for most of them so take that for what it's worth.
https://journals.lww.com/greenjournal/Abstract/2005/05000/Changes_in_Fetal_Position_During_Labor_and_Their.10.aspx This study used ultrasound to track fetal position changes throughout labor, including at 9-10 cm. It found a strong association between EA and OP position at delivery.
https://informahealthcare.com/doi/abs/10.1080/14767050600682487 This study looked at OP births vs OA births and found an association between EA and OP position at birth.
https://www.ejog.org/article/S0301-2115(05)00069-2/abstract This one asks whether the fetal station at the time of epidural placement has an impact on malpositioning. They looked for malpositions at 5 cm because it said they had a routine policy of manually rotating all fetal malpositions during labor. They found an association between EA placement while the fetal head was still high, and OP or OT positions. But since they looked at malpositions at 5 cm instead of 10 cm or delivery, it's hard to draw conclusions from this. Maybe a lot of those babies would have still rotated on their own by the end of labor.
https://onlinelibrary.wiley.com/doi/10.1002/uog.1064/full This study also finds an association between EA and OP position at birth.
https://www.ncbi.nlm.nih.gov/pubmed/20232698 This study finds that while EA did not increase overall cesarean rates, it did significantly increase the rate of cesareans for OP position from 4% to 22%
These are just correlations, not causal relationships. And there are other factors at work. But since I had a c/s for OP baby, it's enough to make me want to stay away from epidurals.
I completely understand. I know you were induced last time, and I'm sure that combined with the position was unnecessarily painful. It will be a totally different experience without Pit.
Those are some interesting studies/results. It appeals to reason that EA would interfere with the ability of the mother to position herself to move the baby. I know two women who had OP babies and had to fight their doctors and labor nurses to use positions that felt most comfortable (hands and knees in both cases).
Ditto what Iris said. My biggest concern with an epi for the VBAC is limiting the positions I can get into. DS's c/s was due to the fact that he went off to the side during his induction. We never were given options to try positioning, etc, but I'll have an experienced doula who can help with that this time. I really want to be able to have as many laboring and pushing position options as I can to make sure that is not a factor.
That said, if it comes down to it and I'm not progressing because I don't feel like I can relax during active labor, I may go for an epi.
I did HypnoBabies with my first, I did not get an epi, and ended up with a c/s after three days of back labor (posterior asynclitic, and VERY stubborn about it). I know it does work well for some people, but HypnoBabies was no where near enough to handle my labor, which was ludicrously painful.
With my second, I did use the breathing techniques and stuff that I remembered from HypnoBabies, but I did not redo the whole program. Labor was orders of magnitude less painful, since she was a lot closer to being in the right position. Even though it was much less painful, I got an epi this time. After a full day of regular contractions that were totally bearable UNLESS I sat or laid down, I was just too tired to keep walking around anymore. The epi let me sleep for an hour. When I woke up, I got out of bed to go to the bathroom (it was a walking epi), and in the time it took to walk to the toilet in my room and back, I dilated from 7 to 10, the epi wore off, and I felt the urge to push. I think the epi gave me just what I needed to rest a bit and get ready for the real deal.
While I wouldn't say everyone should get them or anything, I have no regrets about getting mine and they definitely have their place. IMO, going into it knowing it's there if you need it, but not assuming you WILL need it, is probably the best way to go.