In need of support for potential VBAC

  1. L&D Nurses - I will be giving birth to my second child in mid-September and I'm trying to gather as much information as possible about VBACs. I do have a very reputable and supportive OB, who is in favor of me having a trial of labor if everything looks favorable at the time of delivery, but I would also like some feedback from experienced L&D nurses.

    My previous section was for FTP, maternal hypotension and fever. After an uneventful and very healthy pregnancy, I labored for nearly 22 hours and became stuck at 8cm. My c-section was a nightmare for me, for several reasons including an extremely insensitive on-call doc and a terribly tired and overworked anesthesiologist. Fortunately, my 8lb, 12oz. baby boy was born perfectly healthy and beautiful, and for this I'm eternally grateful. However, I would like to have a better overall birth experience this time around, even if it means a repeat c-section.

    What are your thoughts on issues such as induction and uterine rupture? Do you think I would be better off without an epidural? Or would that increase the chances of receiving general anesthesia if something were to go wrong?

    I've already done a fair amount of research and already have read many of the arguments from those both for and against VBAC. I'm really just looking for your subjective opinions and experiences as nurses because I trust your judgement and think that you all can give me perspective that I'm not going to get from books or articles. Thanks in advance!
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  2. 30 Comments

  3. by   SmilingBluEyes
    Where I work, you would be considered an excellent candidate for TOLAC (trial of labor after csection). And our doctors would NOT discourage it, based on what I am reading of you here. The chances of uterine rupture DO rise after prior csection, but not so much that the risk outweighs the benefit of VBAC--- in your case. Anyone stands a possible 0.1-1% of uterine rupture in labor/delivery, by statistics. The number rises to a potential of up to 5%, after prior csection, but not for everyone. This is a considerable rise, but again not always so much that the risks involved in csection/surgical delivery outweigh that of attempting a VBAC.

    I urge you to consult with your health care providers and see how well they support your desire to TOLAC and then check the unit/birth center at which you plan to deliver. SOME units will NOT do TOLAC/VBAC at all, mostly due to a lack of 24/7 dedicated anesthesia service, or physicians who balk at the risks.

    Most places that do VBAC WILL allow pitocin augmentation of labor but NO PLACE I KNOW will use any method of cervical ripening (cervidil, cytotec or prostin gel), because they are unpredictiable and cannot be "turned off" the way pitocin can. Uterine hyperstimulation is a real risk with any cervical ripening, unacceptable in cases of TOLAC. If you plan a VBAC and have to be augmented with pitocin, where I work, you would be urged to allow internal monitoring of your uterine contractions for accuracy in measuring strength and resting tone of the uterus, as well as frequency of contractions. So do not be surprised if you OB talks to you about placing an IUPC (intrauterine pressure catheter) in labor. It's pretty common. Again, we are trying to avoid uterine hyperstimulation in this case, and titrating pitocin is a more demanding science in cases of TOLAC.

    If you elect to use regional anesthesia, (epidural or intrathecal), you will be monitored VERY closely, but then so are all mothers who elect to use anesthesia. All our mothers who have epidurals are required to be on continuous monitoring, period. Our best indication, esp. if you have an epidural in place, of any rupture of the uterus, is reading/monitoring the tonus of the uterus and fetal heart tones. Any trouble amiss, we can see it on the monitor, usually rather quickly, where you may NOT feel it.

    If you plan to go with LOW intervention labor, then you may be allowed intermittent monitoring, like most others. Women WITHOUT regional anesthesia usually can report symptoms, in the rare case of a rupture. We prefer VBAC's NOT have augmentation, and try to go the low-intervention route, if at all possible, for obvious reasons. The only time you will need augmentation, likely, is if your water breaks and you do NOT kick into labor naturally within about 12 hours or so.

    Also, where I work, IF a woman is TOLAC, dedicated anesthesia personnel AND the obstetrician MUST remain ON THE UNIT during the entire course of labor and delivery. That way, obviously, if an emergency occurs, a very quick response by all critical players is possible.

    I have seen many successful and joyous VBAC deliveries, so I hope to encourage you to try this. BUT your OB and the nursing staff have to be ON BOARD with you and support you 100%. Discuss this early-on with the OB's on your staff, so they are all clear of your intentions. Best wishes and I hope you have a very healthy, happy delivery, however that may occur! I hope this helps a bit.
  4. by   SmilingBluEyes
    I forgot:

    IF you elect to go without an epidural and an emergency arises, yes, your chances of having general anesthesia would be greater, for obvious reasons. If you have an epidural in place, all they do is "dose it up to the max" and do the csection very quickly. There is NO time for spinal anesthesia in the event of a true emergency like uterine rupture.

    If you elect to repeat your csection, expect a MUCH more controlled, pleasant experience . PLANNED csections are MUCH easier than urgent ones, after hours and hours of labor. Your body is not so tired and worn out from labor and you are much more responsive to pain medications/relaxation techniques because your are not circulating so many stress hormones, like catecholamines, to upset things. Also, it's a much more relaxed atmosphere. It is without a doubt a whole different experience, having a PLANNED csection than one done for failure to progress or for emergency reasons, trust me on this.



    Hope this helps. I have tried to give you objective advice here, and I mean in NO way to influence your decision one way or the other. Best wishes!
    Last edit by SmilingBluEyes on Jun 7, '04
  5. by   Elenaster
    Thank you so much for the info Deb, its exactly what I was looking for. I feel like a little insight from "the other side" will help me discuss with my OB what's best for me when the time comes for this baby to enter the world. I really appreciate your feedback. :kiss

    If you ever need any advice on brain surgery or head injuries (god forbid!), I'm your girl :chuckle
  6. by   jnette
    Quote from Elenaster
    Thank you so much for the info Deb, its exactly what I was looking for. I feel like a little insight from "the other side" will help me discuss with my OB what's best for me when the time comes for this baby to enter the world. I really appreciate your feedback. :kiss

    If you ever need any advice on brain surgery or head injuries (god forbid!), I'm your girl :chuckle
    You certainly received input from the best !!!

    Don't have much to offer along these lines (kinda out of my scope..) .. but I do wish you the very best in your pregnacy, birth experience and a healthy, happy new little bundle ! (((HUGS))) and do keep us posted !
  7. by   CHATSDALE
    you can sure learn a lot reading these posts.....we got some people out there GOD love u all
  8. by   fergus51
    Deb said it all! I truly wish more places were encouraging VBACs. We cut far too often.

    Personally though, I don't like pitocin on VBAC women. If I were trying for a VBAC I wouldn't use it. You can turn it off, but not fast enough for my liking. Ruptures just happen too fast. It's just my paranoid nature
  9. by   kids
    Quote from jnette
    You certainly received input from the best !!!

    Don't have much to offer along these lines (kinda out of my scope..) .. but I do wish you the very best in your pregnacy, birth experience and a healthy, happy new little bundle ! (((HUGS))) and do keep us posted !
    Out of my scope too, I don't know nuthin 'bout birthin no babies...but once they leave the hospital I got them covered.

    Do let us know how you and baby are doing.
  10. by   VivaLasViejas
    Elenaster........I myself had a VBAC almost 16 years ago (after TWO cesareans!) when TOLACs were actually encouraged. It turned out to be the best birth experience I had out of the five. I had a doctor who educated me about the risks, encouraged me to stay healthy as possible (I had HTN and was about 300# at the time, but I gained only 17# during the pregnancy), and was allowed to labor naturally. I didn't need so much as a Tylenol during the whole labor, and my son was so alert on delivery he held his head up and looked around the room!

    That was, of course, the optimal VBAC experience, and I owe part of it to the use of guided imagery to control my labor. But if I could do it, I think most women should be able to do it if they want to, and if the circumstances of their pregnancy and labor permit it.

    I wish you the best of luck. Keep us posted!!
  11. by   BRANDY LPN
    Exellent post Deb! Think you covered it all, not much left for the rest of us to add LOL.
  12. by   SmilingBluEyes
    Fergus: pitocin has a very short half-life and turning it off, as well as administering brethine to stop hyperstimulation CAN be done, much more successfully than when prostaglandins like cytotec and prostin or cervidil are used. These are unpredictible and half-lives of prostaglandins can vary by circumstance and patient. I feel relatively comfortable administering pitocin when used with an IUPC as means for assessing uterine tonus and contraction pattern. It is definately preferable to go "natural" when possible, however. But it's not always possible, especially in the case of prolonged rupture of membranes.
  13. by   Energizer Bunny
    Deb...you continually amaze me with your knowledge and your ability to type it up in a way that makes sense.

    Elenaster...nothing to add, just wishing you all the best! I hope you have the delivery that you wish for!
  14. by   nrsnan_1
    SmlingBlueEyes...wonderful teaching! One suggestion I would add is to hire a doula. I believe hiring a professional labor support person helps not just for TOLACs but for just about everyone. I'm not a doula but a L&D nurse. I have been impressed with the doula services. Just a thought.

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