VBAC + epidural or spinal anaesthesia

[babyjellyfish]

I gave birth to my son via EMCS in April 2021. I was induced at 39+5 due to reduced movements. My body had shown no signs whatsoever of going into labour spontaneously, my cervix was completely closed and basically everything they did to try and get me to dilate failed and I ended up having to have a C-section.

I'm currently 33 weeks pregnant and due to give birth again in January, 21 months after the C-section.

I would really like to try for a VBAC but the clinic where I am due to give birth, in France, doesn't have a great track record for VBACs. According to the clinic's statistics, almost 100% of women have an epidural and over 90% of women who have had a previous C-section go on to have another one.

Last week I had an appointment with the obstetrician who will probably be delivering my baby, and she said that once I am in active labour, i.e. more than 3cm, they will want to put the epidural in, just in case we end up having to go for a repeat C-section. She also says that if my labour isn't progressing, I won't be able to labour for as long before moving on to a C-section due to the risk of scar rupture.

Ironically, the anaesthetist, who doesn't get paid if I don't have any anaesthetic, seems more relaxed. She says I could use the bath tub for pain relief in early labour, have an epidural when I ask for one, and she could put the needle in and either not put any anaesthetic in or keep it to a very low dose so that I can stay mobile. She was there for my last birth and looked after me really well. I did have an epidural after half a day of labouring without one, and it worked perfectly and I was still quite mobile afterwards.

I'm not opposed to having an epidural at all, and I don't believe that having one was the reason why my labour didn't progress last time. That said, I am really keen to try for a VBAC and I can't help but feel that the idea that I will be under pressure to have an epidural put in as soon as I'm a certain number of cm dilated, and that once I'm in active labour I'll be on the clock, seems to be setting me up to fail.

Other than trying everything I can think of to go into labour spontaneously, do you have any tips for maximising my chances of having a successful VBAC in these circumstances?

Also, is the obstetrician right when she says it's better to have the epidural in place in case I need to go for a C-section? How quickly could the anaesthetist do a spinal block if I hadn't had an epidural and needed to have another C-section in the end?

Any advice much appreciated!

Obviously speaking very generally, and not considering any obstetric issues with VBAC… An epidural that’s been working well in labour can often be topped up quickly for a c-section, and may achieve anaesthesia quicker than a spinal, and this is one of the reasons that we sometimes talk about early epidurals to women that we think may have ‘difficult’ backs. An epidural that’s patchy/one sided/not given great pain relief in labour is less likely to top-up for anaesthesia and may be better being taken out and a spinal sited for surgery. For most women an untested epidural (eg. putting the epidural catheter in but not using it in labour) is probably the least ideal of the neuraxial options for surgery because you don’t really know how well it’s going to work and putting a spinal in after a full dose of epidural local can get quite unpredictable. (There are some times that a de novo epidural would be used for surgery, but it’s less reliable than spinal for most). HTH.

Thank you.

Does that mean that doing an early epidural in case of a C-section is only worth it if you plan to put in a proper dose and actually test the pain relief during labour, rather than as a "just in case" option?

How quickly can a spinal be done in an emergency?

Re. just-in-case epidurals - there will probably be a variety of opinions among anaesthetists, but I suspect the majority here would not want to use an untested epidural for an emergency section most of the time. Putting an epidural catheter in is not a risk-free process - the OB’s Anaesthetist association has a good info leaflet on the labourpains.com website which may help to decide whether putting one in ‘just in case’ comes with a risk of side effects that you’re happy to accept. It sounds like the anaesthetist you spoke to is comfortable doing this so may be worth exploring the pros & cons that particularly relate to you with them as well.

re. how quickly a spinal be done - it varies. Sometimes they ping in first time & it only takes minutes. Sometimes it takes a lot longer. How hard we would try depends on the degree of urgency and how high risk the alternative (a GA) would be.

lots of medicine isn’t very black and white, and it’s really best to take the advice of the people who’ll actually be looking after you as they can take into account any medical issues you may have, what works well in their hands, and what issues are likely to arise relating to your delivery. HTH

From a different perspective, I would have a look at what your odds of a successful VBAC are in case that influences your choice. And whether/how they will induce you if you don’t labour again, when they would move to a section if that didn’t work, and how you feel about that.

I had an EMCS after being induced due to being overdue and failed to dilate beyond 2cm during the induction. The research I did (looking at things like RCOG papers) made me conclude that the odds of a successful and straightforward VBAC were not high given the reason for my previous section (ie mum-related and failure to dilate rather than baby in distress, etc).

I wasn’t prepared to be induced again so booked a section for 41 weeks. I didn’t labour so I had the section. For me, it was the right decision.

Thanks for the response, @Greybeardy.

I am giving birth in a clinic where there are four anaesthetists, and the one I had my consultation with last week is the one who took care of me during my last labour and C-section. Just crossing my fingers that she is the one who is there on the day, because she was excellent and I trust that she knows what she's doing.

Thanks @MyBuggyIsOutToGetMe. Struggling a bit with some of the online calculators because in my notes it says the C-section was for foetal distress, i.e. a non recurring reason, whereas I know it was a combination of that and failure to progress. I was in labour for about 12 hours between them breaking my waters and moving to a C-section. My body wasn't ready to labour, and when they turned the syntocinon up to a high dose my baby's heart rate dropped. I'm not sure whether I'd have got to second stage if I'd been left to labour overnight, I know some women go a lot longer and get there eventually. I think I got to about 6cm.

Like you, I don't fancy being induced again, even though they would be willing to do it, and so I think I will book in for an ELCS at 41 weeks if I don't go into labour before then. My issue is more what to do about the early epidural if I go into labour spontaneously and decide to try for a VBAC. I'm not very keen on the idea that I "have" to have an early epidural in case of a C-section, because it seems like it's setting me up to fail.