--An Unmedicated VBAC? Really? --Yes, Really!

My client was underneath a heated blanket, her naked newborn boy snuggled on her naked chest. She was marvelling at how special the immediate skin-to-skin experience was, particularly because she had delayed skin-to-skin with her first, as she was born by c-section. This was one of her largest motivators in aiming for a VBAC.

"That was amazing," she said. "I can't believe I did it."

"Not only did you do it," chimed in the attending OB from where she was counting instruments, "but you did it unmedicated. Almost no one can say that."

My client's VBAC certainly is a personal victory; given today's VBAC climate -- despite the NIH findings that a trial of labor after a c-section is actually safer than a repeat c-section -- it is a political victory as well. But the OB's comments are sticking with me because my witnessing of unmedicated VBAC seems to be the direct opposite of hers. I have attended about a dozen VBAC's in the past year, and all but 2 did it unmedicated (and those two had c-sections, one after a trial of labor, the other with no trial of labor).

Looking at older (2005) statistics from the MA Department of Public Health, epidural use was between 60-70 percent at the hospitals I frequent the most. Whereas those who work on L&D have seen probably thousands more births than I ever will, I think I have been a part of more unmedicated births because I am trained and experienced in specific, non-pharmacological, emotional and physical comfort measures that provide pain relief, and because I provide home support -- where that is the only option available.

My client had been admitted at 8cm, and was showing some of the "classic" signs of transition. All kinds of things were coming out of her mouth. Her sentences, all stream-of-consciousness and irrational, generously peppered with various forms of the word "f*ck," were basically amounting to the fact that she didn't want another single contraction, and that she wanted to put on her clothes and go home. When she said she couldn't figure out if she needed to pee really badly or if she needed to have a bowel movement, she began asking for an epidural.

When the OB said she was dilated to "9 and a lip" (a lip is a bit of remaining cervix that has not dilated), all my client heard was that she wasn't 10 cm, and her request for an epidural turned into a demand. Feeling the arc of this birth unfolding, I did exactly as I had promised her I'd do if she asked for an epidural -- talk her out of it. I explained to her that all the pressure she was feeling was the baby moving down through her pelvis. She resisted, saying again that either she wanted to put her clothes on and go home, or get an epidural. The nurse said, "OK, if you're sure an epidural is what you really want." She said it with great hesitation, probably because she knew this baby's birth was not far off, and because by the time anesthesia would have gotten there and placed the medication, the baby would have been born already. And probably because she didn't know what else to say, other than the words she needed to order an epidural .

Knowing that pushing would be a relief, as it is for many women, I said to her, "Pushing and getting this baby out is the best pain relief you can get." I asked the OB quickly, "Can she push past the lip?"

The OB took a deep breath and carefully considered my question, and I wondered if she'd ever been asked that before. I could practically see the light bulb going off in her head before she said, "I don't think that pushing past the lip will interfere with her progress at all."

My client needed convincing to push, so I suggested she push just to try it, and see if it helped any. The lip was anterior (towards my client's pubic bone), so I suggested she get back on hands and knees so that the baby's head would finally press out that lip. She pushed with the strength of an army of men, and 20 minutes later, my client was holding her baby in her arms.

What would have happened if my client had gotten the epidural, assuming that there would have been time to place it? Her baby was coming with such force that it is doubtful an epidural would have slowed the contractions, especially at 9+cm. For the same reason, I can't imagine it would have drawn out the pushing stage into anything long and exhausting, as can also happen with an epidural. She would have had a happy and healthy baby, and she would have done so via VBAC. And retrospectively, perhaps she would have been just fine with getting the epidural, especially when she'd get to the part of the story where she would describe the amount of pain she was in. It all would have been fine, probably, but I am thrilled that my client does not need to reconcile her goals for her birth with its outcome.

Lesley Everett, a doula in Montreal, just led a doula training for L&D nurses. The snippets of what she shared from that experience are encouraging -- many of the nurses who attended expressed some layered frustrations; not only do they not have the knowledge on how to support women who are laboring without an epidural, they have too many patients at one time to provide the focused and concentrated work of unmedicated labor support. Combine that with the fact that the spectrum of emotions and behaviors that unmedicated women present with can be pretty darn intimidating if you are not accustomed to it. What results is a lack of practice, which leads to lack of confidence, which leads to a lack of practice.

I am heartened by Lesley's work, and I'm hoping that my client's birth experience prompted some out-of-the-box thinking for the hospital staff involved, a gentle reminder that babies are born in hundreds of ways, as long as the mothers have knowledgeable support.





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