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VBAC Cubby - vaginal birth after cesarean

Epidurals With VBAC
by Nancy Sullivan, CNM, MS, FACNM
Nancy SullivanQ. I would like to try VBAC, but my OB was insinuating that it was dangerous because of possible rupture, and that I would not be able to have a full epidural so that I could tell if a rupture was happening, etc. Do you find that your patients have good luck with VBAC?

A. Ah, your question is the question of the moment. VBACs seem to have become a hot topic because the American College of Obstetricians and Gynecologists revised their statement on VBAC recommending that there be "immediate" access to cesarean section for women undergoing a trial of labor after a previous cesarean. This means that women should labor only in a hospital that can provide immediate cesareans - that is, one where a full team, surgeons, anesthetists or anesthesiologists, nurses, etc. are available at all times. This is true only in major medical centers; therefore, obstetricians in smaller hospitals are doing fewer VBACs and refusing to back up midwives to do them.

The reason for this increased concern seems to be a real increase in the number of uterine ruptures over the past ten years, from about one per thousand to one per hundred. That is a big increase. Many reasons have been put forth as to why this is so, including epidurals, inductions and augmentations with pitocin or prostaglandins. Cytotek or misoprostil was implicated, and most OBs and midwives have stopped using that for VBACs.

However, the most recent evidence seems to show that the increase in ruptures may be associated with a change in the way the uterus is put back together after a cesarean. It used to be repaired in two layers, and gradually over the last ten years obstetricians have switched to a one-layer technique, which is (guess what) quicker to do. The scar with this new method seems to be weaker, hence . . . more likely to rupture when contractions put stress on it during the labor.

So, there really IS more reason to be concerned than there used to be. The obvious solution seems to me to go back to the two-layer method of repairing the uterus, but I haven't heard much talk about this. Instead, obstetricians are just recommending more repeat cesareans, or more restrictions on women who want to try for a VBAC.

Epidurals have not, in fact, been implicated in the increase of ruptures. It used to be thought that the women would have a lot of constant pain if her uterus was rupturing, and be able to tell the nurse or doctor, and that an epidural would mask this sign. However, most ruptures seem to be relatively painless, at least, no more painful than the labor is already. So this isn't a useful sign. The only sign that seems to forewarn of rupture seems to be variable (V-shaped) decelerations in the fetal heart rate on the electronic monitor. Unfortunately, these are also extremely common in normal labors, so that presents a problem. Should every VBACer be sectioned immediately if she has variable decelerations? No one seems to know the answer to this.

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