The birth of Brody

VBAC 2 - With different reasons for both.

Hi Dr David,

Thanks for being here for us! My question is if I become pregnant for a third time, what are my chances of a vaginal delivery after:

First caesarean 10days overdue for foetal distress - mega-emergency after only a few hours of very mild labour. We are very lucky to have our 5lb 13oz little girl thanks to a wonderful obstetrician. The placenta was severely infarcted.

2nd caesarean: Had ultrasound to check placenta was ok a few days before which it was. Was induced as I think my blood pressure may have risen slightly - certainly not seriously and probably because we just found out we had to move house. Plus my doctor was due to go overseas and it was just before Easter. (I am sounding a bit cynical?) Had my waters broken 7am, then "rebroken" a couple of hours later, then drip inserted about 1pm, laboured until 6.30pm when dr decided baby was not progressing. I was 6cm dilated. He said he had to do a caesarian. WHY? I wish I knew. My baby was big 9lb 7oz but surely the insertion of an epidural could have made a big difference? I did have an epi for the ceasar and I really relaxed a lot when that went in and I stopped using that terrible gas (which makes me very emotional).

Here are my questions:

What do you think about an epi helping to deliver vaginally? (I ask this particularly because my girlfriend just delivered her first baby 8lb12oz vaginally and she is tiny. Her dr said she had to have an epi or else there was no way she could have endured it. I wish I had her dr and I will use him next time.)
Would you have induced someone like me? Wouldn't it be a better option to let labour begin naturally after a previous caesarian?

Sorry for writing so much, but as you probably know, this really has affected me deeply. I REALLY want a natural delivery next time, but the thought of labouring and then having a ceasar is terrifying.

THANKS A MILLION.

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Dr. David

Moderator posted 21 February 2001 08:33 PM

Kayelle

You ask "What do you think about an epi helping to deliver vaginally? "

The short answer is that there is no evidence that epidural analgesia increases the chance of natural birth, in fact it increases the chance of forceps or vacuum, and may increase the chance of caesarean. (see Enkin et al. A Guide to effective care in pregnancy and childbirth). Timing of epidural may be important however, with these adverse effects present with epidural in early labour. However, studies can never answer the question of what will happen in an individual person. Some women may feel that the only way to continue a labour, or to even contemplate it in the first place, is to have available adequate pain control with an epidural. Remember that continuous support in labour has no side effects and (at least in non-VBAC women) has been shown to decrease the need for pharmacological pain relief in labour.

There are no randomised trials of epidural in VBAC, but a huge (and often a little confusing) amount of reported experience:

Epidural and VBAC (with thanks to ICAN VBCA source book)

Sakala &endash; epidural had no effect on operative delivery rate in attempted VBAC

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2231564&dopt=Abstract

Molloy (Irish 1979-84) &endash; low epidural rate (4.8%) in 2176 women with one previous Caesar. "When a patient was adjudged suitable for vaginal delivery she was managed as a normal multiparous woman", including induction or augmentation if needed. Low rupture rate (0.45%), but significantly higher if oxytocin and epidural (6%). "Clearly great caution must be exercised before considering the combination of oxytocin and epidural analgesia in such subjects. On the other hand, the patients who needed this form of management would, otherwise, have been delivered by emergency caesarean section".

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3113567&dopt=Abstract

Caughey (US 84-96) Rupture rate 0.8% with one previous Caesar (3757 women), 3.7% if 2 previous caesars (134 women) with oxytocin use in 36 and 38%, epidural use in 70 and 72%, and VBAC rate of 75 and 62% respectively. Amongst 36 ruptures though, only one baby and no maternal deaths.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10521745&dopt=Abstract

There are many journal articles on VBA2C. A summary of the evidence suggests VBAC rates 65-75% (slightly lower than if one previous Caesar), and rupture rates of 1-3.7% (somewhat higher than if one previous Caesar).

Spontaneous labour has a lower risk of rupture than labour induced by oxytocin or prostaglandin. Your doctor tried just ARM first.

"The thought of labouring and then having a caesar is terrifying". This is probably the most important sentence in your post. There is a definite chance (about a quarter to a third) of you needing a caesar (but a higher chance of vaginal birth). This fear is something you will need to confront then work through prior to your next pregnancy. Many women have written inspirational stories of their journey past this fear and recorded them in books and on this website. Kayelle, you've started your own journey by writing here. Knowledge is strength. I'd encourage you to continue to seek support from women via the discussion forum or local support group.

Dr.David

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Dr David 2nd Response:

Moderator posted 22 February 2001 02:19 PM