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Monday
Dec142009

Monday Reading: Inductions, VBACs, Building a Birth Team and More

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Mom’s Tinfoil Hat did some interesting reading on elective inductions in nulliparous women for psychosocial reasons, Bishop scores and how Cervidil is contraindicated in cases of suspected CPD (which would most likely be suspected macrosomia).

 

A story about a quick VBAC earlier this year.

 

I loved this round-up of articles about AMAZING MIRACLE BABIES NOT BORN IN HOSPITALS, complete with evidence of the media’s umbilical cord cutting fetish.

 

Birth Sense recalled several of the times in her career in which women were treated horridly during or leading up to their cesarean section.

 

Preparing for Birth posted about building a birth support team.

 

In response (but not totally related) to the post A Case of Statistical Malpractice? Predicting the Risk of Uterine Rupture on Science & Sensibility and after having heard from a few women that their friends were being denied a VBAC unless they consented to epidural anesthesia, I asked how common it was. Here are the first 20 responses on the Facebook fan page:

 

A client of mine is being told she must have an epidural to have a trial of labor. She is in the process of considering other options because this is unacceptable to her.

 

A local OB I has told me he will only do VBACs if the woman consents to an epidural. He claims its hospital policy but that’s BS.

 

Interestingly enough, I’ve also heard of the opposite. One of our local hospitals with a VBAC ban recently instituted a policy that if a woman refuses a repeat c/s they can and will deny her an epidural until she consents to the repeat c/s.

 

I have definitely had clients being pressured to have them. Most have switched docs after hearing that BS!

 

I haven’t been refused my VBAC but I can definitely see that my OB thinks the epidural a) speeds labor and b) makes thinks faster in case of an emergency rupture. But having mentioned it once, he hasn’t brought it up again, thankfully.

 

WOW this is shocking. I have not had one VBAC client that has been told she needs to have an epi. All of my VBAC births at the hospital needed to have I.V.’s, and intermittent FHM, but that is it. My clients that choose to have a VBAC at home need to at some point have an OB consult, but that is about it.

 

I know of one here in Alaska who was able to deliver a breech VBAC but only if she agreed to deliver in the OR with an epidural. He said it was for the forceps that he planned to use (and did use) very ungracefully. He said that she had to have an epi because he “can’t stand the screaming”.

 

Last week, when I was checking in to do this VBAC. The nurse-anesthetist came in and tried to convince me that I should get the epidural. She tried the dead baby card, and even offered to place the tube in my back so they could put the medicine in “just in case”.

I wonder if the result of this study has to do with the women not being able to feel that something is not going right. Or maybe trying to up the painkillers to cover the feeling. Or maybe laboring in bed just is harder on the scar then moving around.

 

i had a client w/ twins (NOT a vbac) who was forced against her will to take an epidural, then push w/ no support in the OR. the OB said she could have the epidural or an immediate c/s, period. the woman was sobbing. then after she got the epi, the OB told her if she had a c/s she probably would get general. one of the worst abuses i have ever personally witnessed.

 

I’ve heard of this on several occasions. In this area, it seems to be a very common policy to require IV, continuous fetal monitoring, and an epidural IF they’ll agree to VBAC at all. They claim it’s so they can just up the epidural and not have to put her under general if she ruptures.

 

I transferred form home to hospital for my first vbac and requested an epi. They told me they would get it to me right away if I consented to a repeat c/s. They held this over my head! I refused to sign the consent so instead they made me wait for 4-5 hours. No explanation. I was 8cm when I was admitted and I think I actually may have been complete when I finally got the epi.

 

I’ve been searching for a truly VBAC-friendly provider the last few months (not pregnant now—just want to establish care for when the time comes) and I haven’t found anything saying I must have an epidural or else, but I HAVE found a doctor that said he strongly encourages all women to get a port for the epidural, even if they’re not planning to pump the medicine in, “just in case.” Right. Just in case. :/

 

I had a VBA2C and no one forced me to have an epi… an IV and FHM yes but not an epidural.

 

My hospital VBAC clients (Detroit MI area) have all been told continuous monitoring, iv, & they have recc’d epidurals. Sometimes they push the epi hard, sometimes light… not had anyone yet *required* but I have had several clients who’ve switched provider to more vbac friendly folks…

 

my doc actually told me my chances of VBAC would be GREATER if I DON’T get an epidural…

 

Considering that the epidural allows them to push Pitocin without limitations, I would argue (and this has been born out in the literature) that spontaneous labor has the lowest risk of uterine rupture (lower than Pitocin induction or augmentation).

 

i have see twins w/ a mandatory epi in place and the delivery in the OR used more than a few times….

 

I believe the town I am from will not do VBACs w/o consenting to induction. A neighboring town (bigger than mine) will do them, however. Not exactly the same thing you are asking, but bothers me still. I imagine a lot of them who do have VBAC end up getting an epi here because of that policy, but I would have to ask around as I do not know many who have had one from my town.

 

It’s all very bizarre. You would think that they wouldn’t want you to have an epidural b/c then you wouldn’t be able to feel anything (to tell them) in the rare case of a rupture. Also, my OB said no induction b/c Pit can cause violent contractions that can actually CAUSE rupture. Interesting that the statistics are relatively the same for uterine rupture resulting from attempted VBAC AND regular induction with no scar (which is performed all the time!)

 

When I had my VBAC, my doc told me she’d rather i did NOT have an epidural if at all possible because she felt I’d be more likely to be able to tell her I felt something wasn’t right. She also refused to use any pitocin for a VBAC. She did warn that if an emergency c-section became necessary, the chances were greater that I’d have to go under full anesthesia. That was a risk I was certainly willing to take! It seems I was very very lucky to have a supportive doc and hospital.

 

Are you aware of women being routinely denied VBAC unless they consent to an epidural? Send me an email at unnecesarean [at] gmail or leave a comment.

 

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Reader Comments (5)

Thanks for the linky love!

I have definitely read anecdotal reports of epidurals required for attempted VBAC.

December 14, 2009 | Unregistered CommenterMomTFH

My own experience at my local hospital was a policy that all VBAC patients meet with the on-call anesthesiologist during labor. My pro-VBAC OB's explained this to me up front and said that this meeting had not always been a positive experience for their VBAC patients. That it had varied greatly with the personality and mood of the on-call anesthesiologist. I expressed a desire to decline this meeting and I placed in my chart written instructions that I not be offered medication during labor; I would request if necessary. Somehow the anesthesiologist never showed up during the 12 hours I was at the hospital before giving birth.

Since almost all hospitals interpret ACOG's VBAC guidelines as requiring an available OR and anesthesiologist for the duration of the VBAC labor, this seems like it could be ripe with potential for abuse. Certainly the anesthesiologist on call the night my second son was born didn't get to bill me for anything.

December 14, 2009 | Unregistered CommenterLaura

Laura, thanks for your comment. I'm thinking this trend (if it is common enough to call it a trend) would be hard to investigate because not only would things vary policy-wise from hospital to hospital, but from doctor to doctor, CNM to CNM and anesthesiologist to anesthesiologist.

December 15, 2009 | Registered CommenterJill

I came across this post searching for a reason why a doctor would say I had to have an epi put in "just in case". My doctor has said this at my last three appointments like she wants to make sure I hear her. I just keep telling her I don't want one. I guess I will see how it goes it is to late to change doctors now.

January 28, 2010 | Unregistered CommenterNicole

Hi Nicole,

She can't force anything on you. Depending on how into it you want to get with her, you can ask her to show you the evidence that supports her recommendation. Have you had a previous cesarean and she's concerned about the worst case scenario of a uterine rupture and need to perform a cesarean immediately?

Can you round up a doula to support you during your birth? Some hospitals have volunteer doula programs. It can be really hard and very stressful to fight off unnecessary drugs and procedures while in labor. And really, not consenting to an unnecessary, elective intervention that you don't want isn't the least bit weird.

I'll e-mail you this comment. Let me know if you want me to help you find an advocate in your area that knows the local doulas, etc.

January 28, 2010 | Registered CommenterJill
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