VBAC Scare Tactics (7): Playing the Epidural Card
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.
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.)
What’s more, the studies on uterine rupture from the eMedicine overview also conclude that “prolonged, late, or recurrent variable decelerations or fetal bradycardias are often the first and only signs of uterine rupture” and occur in roughly 80% of uterine ruptures. Accordingly, if any fear-based requirement were to be made of moms attempting VBAC, it should be continuous fetal monitoring and not epidural restriction–and even this requirement should be left up to the informed discretion of the mother, in my opinion!
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 serious 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 significant 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.
*While I find ACOG’s educational pamphlet on pain relief during labor to be lacking in many respects (its patronizing descriptions of the side effects of medication and its warnings about eating before or during labor come to mind), I think that it does a decent-enough job of explaining the differences between the various analgesic and anesthetic pain relief options available to mothers in the U.S.