VBAC Scare Tactics (7): Playing the Epidural Card

VBAC Scare Tactics (7): Playing the Epidural Card

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Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in the U.S. have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.  Oftentimes, this opposition comes in the form of ” VBAC scare tactics.”

The (outrageous) statements are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

And if you find yourself up against a barrage of scare tactics–as I once did–it can be exceedingly difficult to stake your claim and argue against the doctor (again, or midwife) who may or may not have your and your baby’s health prioritized higher than medico-legal concerns and who may or may not be hurling phrases like “catastrophic uterine rupture” and “dead baby” your way.

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.

I encourage all mothers who read this post (and others in my “VBAC Scare Tactics Series”) to  take the information contained herein as a springboard from which they can 1) continue their research on VBAC, 2) maintain a communicative relationship with their care providers, and 3) find a care provider who best supports the mother’s interests and plans for the birth of her child.

(To read my disclaimers about “why I am not anti-OB” and “why I take the gravity of uterine rupture seriously,” please see my posts on VBAC scare tactics (1) and (2) .)

 

Scare tactic #7a: An epidural can mask the signs of uterine rupture, so I do not permit my VBAC patients to have an epidural during their labors.

Scare tactic #7b: In case of an emergency cesarean, I require all of my VBAC patients to have an epidural in place in early labor.  That way, we will not have to wait for the anesthesiologist to get the epidural in place if a uterine rupture occurs.

 

Questions to ask your care provider in regard to 7a:

  • How often is severe abdominal pain an indication of uterine rupture?  Is this the only or even the primary indication of uterine rupture?
  • Does an epidural always obscure the pain of uterine rupture?
  • Do I have any other pain relief or medication options during labor?
  • Would I still have the right to request an epidural if I absolutely wanted it during labor?

Questions to ask your care provider in regard to 7b:

  • How long does it generally take for an anesthesiologist to get an epidural or spinal in place?
  • Are there any other anesthetic options besides an epidural or spinal if a uterine rupture (or other birth emergency) were to occur?
  • What are the risks associated with epidural analgesia?
  • What would happen if I were to refuse an epidural during labor?

 

A more nuanced analysis:

It should be noted that these limitations will not seem coercive to every mom who hears them.

For the mother who has planned and prepared for a drug-free childbirth, it will be highly unlikely that she will be deterred from seeking a VBAC upon hearing that she will not be “allowed” to have an epidural.  On the other hand, for the mother who has every intention of requesting epidural analgesia during her labor, it will be highly unlikely that she will be deterred from seeking a VBAC upon hearing that this medication will be required during her VBAC attempt.

But (and you can see where this is going), the mother planning and preparing for a drug-free childbirth who hears that she must have an epidural AND the mother who wants an epidural yet hears that she cannot have one might very well be scared away from attempting a VBAC.

And this is particularly disconcerting since neither requirement regarding epidurals has much basis in fact or necessity.

In fact, as reported on eMedicine’s overview of the research on uterine rupture (“Uterine Rupture in Pregnancy”), in cases of uterine rupture:

…sudden or atypical maternal abdominal pain occurs more rarely than do decelerations or bradycardia. In 9 studies from 1980-2002, abdominal pain occurred in 13-60% of cases of uterine rupture. In a review of 10,967 patients undergoing a TOL, only 22% of complete uterine ruptures presented with abdominal pain and 76% presented with signs of fetal distress diagnosed by continuous electronic fetal monitoring.(Johnson C, Oriol N. The role of epidural anesthesia in trial of labor. Reg Anesth. Nov-Dec 1990;15(6):304-8.)

Moreover, in a study by Bujold and Gauthier, abdominal pain was the first sign of rupture in only 5% of patients and occurred in women who developed uterine rupture without epidural analgesia but not in women who received an epidural block.  (Bujold E, Gauthier RJ. Neonatal morbidity associated with uterine rupture: what are the risk factors?. Am J Obstet Gynecol. Feb 2002;186(2):311-4).  Thus, abdominal pain is an unreliable and uncommon sign of uterine rupture. Initial concerns that epidural anesthesia might mask the pain caused by uterine rupture have not been verified and there have been no reports of epidural anesthesia delaying the diagnosis of uterine rupture. A guideline from the ACOG from 2004 suggests there is no absolute contraindication to epidural anesthesia for a TOL because epidurals rarely mask the signs and symptoms of uterine rupture.  (ACOG. Vaginal birth after previous cesarean delivery. ACOG practice bulletin no. 54. Washington, DC: American College of Obstetricians and Gynecologists;2004).

In this respect, it seems unwise–if not cruel and in stark contrast to the evidence–to forbid a mother from requesting epidural medication during a VBAC labor simply because an epidural may “mask the signs of uterine rupture.”  (Notably, some women with epidurals in place even report experiencing the pain of uterine rupture when it occurs.)

Notably, there are other pain management options during labor besides epidurals.  Narcotic pain medication (such as Stadol or Demerol) can provide some relief during labor, but these medications do present potential risks to moms (including drowsiness and vomiting) and to babies (including central nervous system depression and respiratory depression).  But besides pharmacological pain-relief, there are numerous risk-free non-pharmacological pain-relief options during labor that moms can make use of, including but not limited to walking, changing positions, hot and cold packs, aromatherapy, doula support, and vocalizing.  These comfort measures can be helpful to a birthing mother even if she only needs some “tricks” to help in the time that she must wait for pain medication to be administered.

However, for the mother who does not want an epidural (and for the mother who does, for that matter), it is important to note that epidurals also have potential risks and negative side effects.  These risks include itching, nausea and vomiting, spinal headache, fever, and, more rarely, convulsions and cardiac or respiratory distress.  In addition, epidurals present a unique “risk” to VBAC-ing mothers since epidural analgesia can slow a baby’s heartrate, thereby giving off a “false alarm” that a uterine rupture has occurred.  These risks in and of themselves should give mothers solid ground on which to contest their care provider’s declaration that moms attempting VBAC must use an epidural.

Furthermore, it should be noted that while a symptomatic uterine rupture is an emergency and does require immediate intervention, this does not mean that an epidural must be in place “just in case” a uterine rupture were to occur.  For one, uterine ruptures occur in approximately .7% of all VBACs (and the study here cited includes induced VBACs.)  Despite the seriousness of this risk, the relative infrequency with which it occurs does not seem to warrant taking such an extreme measure as requiring a woman to have an epidural during her labor.

In addition, general anesthesia*–which takes effect very rapidly–is usually an option for a cesarean in which the mother and/or the baby are in severe distress (such as in the case of a uterine rupture).  Although not ideal  for the woman who wants to witness her child’s birth, general anesthesia does offer an alternative form of surgical anesthesia “just in case” a uterine rupture were to occur.  (Worth noting too is that a readily available anesthesiologist may be able to insert an epidural anesthesia within minutes so that a mother can still be awake for the surgical birth of her child, even in the event of an emergency.)

It it also worth pointing out, however, that the epidural analgesia that a mother receives during labor is generally not effective enough for a cesarean section.  Thus, the epidural medication must be increased*–a process that does take time–before a cesarean section.  And this means that having an epidural in place during labor will not guarantee that a cesarean surgery will be able to be performed immediately simply because the epidural is already inserted.

And finally, creating any sort of non-evidence-based requirement regarding epidurals for mothers attempting VBAC undermines these mothers’ patient rights and autonomy.  And while this “risk” of epidural-requirements or bans is mostly theoretical, it is a risk that should give every woman (and man) pause…and perhaps enough pause to challenge their care provider and/or seek out a new one.



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11 Comments

  1. enjoybirth
    enjoybirth09-09-2009

    Ooo, this is great. I just went and read all your VBAC scare tactics. Great information to help moms decide what is best for THEM!

  2. Mike
    Mike01-23-2011

    Hi. I’m an anesthesiologist so just wanted to give a couple points from my side of the fence.

    I agree an epidural is certainly not contra-indicated in VBAC and very unlikely to mask the signs of uterine rupture.

    I’m an advocate of patients having an epidural during a VBAC. The main reason is that it DOES allow a relatively quick way of providing surgical anesthesia if emergency surgery is needed. One should also realize that an epidural can simply be sited, and tested, and then not used for labour pain management (but available to be used for an emergency). Performing a spinal is USUALLY quick and easy and can be done in minutes. However, this is NOT always the case. Sometimes it can be technically difficult or impossible to place a spinal in an emergency situation.

    In regards to general anesthesia and c-section, there is substantial literature that shows that general anesthesia (especially for emergency c-section) carries significantly higher risk to both the mother and baby (probably on the order of 10 fold increase). Usually this is because the airway changes that occur during pregnancy and labor make it difficult or impossible to place a breathing tube.

    The only time I strongly suggest an epidural is when I assess a VBAC patient and see that their airway looks difficult. This would be a warning sign to me that I could NOT safely do an emergency general anesthetic. How do you know if your airway is difficult? Well thats a whole other topic, and really can only be determined by an anesthesiologist assessing you at the time of labor.

    I think alot of the ‘scare’ tactics result from the rare bad case or outcomes that occur. We must remember these are rare events that we try and prevent from happening. When you are involved in a case of uterine rupture with bad outcome, it is a truly tragic and scarring event.

    If we could be better at predicting which VBAC’s will successfully go on to deliver vaginally that would allow us to make better decisions.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas01-25-2011

      Mike, thank you so much for taking the time to share your perspective! I’m especially interested re: your point about strongly suggesting a “just in case” epidural after assessing a woman’s airway. For women who might be at a higher risk for uterine rupture (i.e. those with more than 2 previous cesareans, those whose labor is induced with pitocin, etc.), this could be something they might want to know prior to labor (and especially after they are admitted to the hospital)!

      And I truly take your point about the effects that bad outcomes can have on care providers. In fact, I wholeheartedly support those care providers who tell their patients, “I’ve experienced one of those rare bad outcomes with VBAC, and this has made me choose not to attend them anymore. The evidence does support the relative safety of VBAC for most women with a previous cesarean, however, so I can give you the names of other local care providers who do attend VBACs if this is your choice.” In my mind, this is much different from (perhaps unwittingly) giving women misinformation about VBAC in order to encourage them to schedule a repeat cesarean.

      • Mike
        Mike01-31-2011

        Just my personal view.. But I would probably prefer to have someone experienced that HAS been involved in the bad outcomes and disasters.. because when they happen the decisions that have to be made are difficult and take experience to save both the mother and babies lives.

        The facts are as follows
        1) Most VBAC’s go on to have normal vaginal deliveries.
        2) Elective C-section is riskier to both mother and baby than SUCCESSFUL VBAC.
        3) EMERGENCY C-section after FAILED VBAC is VERY MUCH riskier than elective C-section.

        So you see its a dilemna. Option 1 is best case, but we end up with worst case option 3 if it fails. Should this mean we choose option 2 for everybody?? Probably not. Certainly we would choose option 2 if we knew in retrospect that option 3 would occur. Should we choose option 1 all the time??? Probably not either.

        We need to figure out predictors of successful VBAC. In the meantime it is all risk mitigation.

        • BirthingBeautifulIdeas
          BirthingBeautifulIdeas01-31-2011

          Have you seen Grobman’s VBAC success prediction calculator? It is by no means a perfect predictor of VBAC success, but it’s a “start,” so to speak. What’s more, I think that the choice between a VBAC and a repeat cesarean will always be a matter of risk mitigation. I’m not sure that there would ever be a way to predict VBAC success with even 90% certainty, especially since most unsuccessful VBACs are not associated with uterine rupture but are associated instead with any other number of indications for cesarean section. With that being said, I do agree that creating reliable prediction models should be a goal for those doing research on VBAC.

          In that same vein, I am aware of the spectrum of risks, and I realize that this makes a choosing between a VBAC and a repeat cesarean a difficult choice for any woman faced with it. But I think that it would be best to present the risks and benefits as accurately and transparently to women themselves, inform them of any additional and unique risk factors they might be facing, then let them make their own birthing decision.

          • Mike
            Mike01-31-2011

            Agreed. Unfortunately informed consent is done very poorly and usually with great bias both on the part of doctors and midwives.

    • Anne
      Anne06-08-2011

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      I see this analysis alot and it is generally accepted as true.

      However, I want to stress that with #3, it appears to me we are talking EMERGENCY c/sec. I recently attempted my second VBAC, but baby kicked my waters in the process of turning breech and deciding to ascend instead of descend (we later found out he had a 2x nuchal cord that probably contributed to this whole chain of events). I have to say, this c/sec was MUCHO better than my scheduled c/sec for #1 for breech. So I guess my point is, failure of #1 does not always = #3. There needs to be a fourth point added, because not all c/secs after a TOL are EMERGENCY c/sec. Mine was never an emergency, it just became apparent that baby was not likely to come the traditional way and that a c/sec was probably a more prudent option than “wait until this becomes an emergency.”

      • BirthingBeautifulIdeas
        BirthingBeautifulIdeas06-08-2011

        Oh, absolutely. In fact, IIRC, I think that most c-sections after a VBAC attempt/trial of labor are non-emergent (or at least not as grave a situation as a uterine rupture).

        I think that the reason I focused so much on emergency c-sections is that most dissuasion from VBAC–or at least most “VBAC scare tactics–hinges on discussion of uterine rupture, which is an emergency. But I think you’re right that I should point out in edits that these c-sections following TOL are most likely the exception rather than the rule.

        • Alexis
          Alexis06-24-2011

          Medically, a section is either emergent or elective. Elective merely means scheduled, not maternal request. Emergent doesn’t mean crash. My own section is coded as emergent even though I was not in labor at all. (I had severe preeclampsia and failed my non-stress test; I was in the OR half an hour later.) So yes, when they compare emergent to elective in studies, all the sections performed after labor has begun would be classed as emergent. Outcomes are, on average, worse, because your body has been through the stress of both labor and surgery.

          • BirthingBeautifulIdeas
            BirthingBeautifulIdeas06-24-2011

            You’re right–sometimes it’s hard to walk the fine line between writing colloquially and writing in the way that something is medically coded. Even “in between” those are the ways in which some doctors and nurses even talk about the varying levels of urgency of c-sections “in the moment.” And to that effect, it would be more accurate to say that not all c-sections following trials of labor are “stat cesareans,” as would be the case during a uterine rupture.

            And I could write pages and pages about misconceptions of the difference between how “elective” cesareans are coded, and how they are talked about. :-)

  3. BirthingBeautifulIdeas
    BirthingBeautifulIdeas09-09-2009

    Thanks so much for the input–and for the link! And I’m glad that you read my posts on VBAC scare tactics as information that can help empower moms to decide what is best for them. This has certainly been my intention!

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