The role of epidural anesthesia in trial of labor

In 1988, the American College of Obstetricians and gynecologists (ACOG) decided that vaginal delivery after a previous cesarean delivery (trial of labor, TOL) was an acceptable alternative to elective repeat cesarean delivery. ACOG stated that there appears to be no absolute contraindication to epidural anesthesia for labor during TOL. The concern is that should there be a uterine rupture, would the epidural anesthesia mask the abdominal pain? The incidence of complete rupture with trial of labor is reported to be 0.3-0.5%. In our review of 10,967 patients undergoing TOL, only 22% of complete ruptures presented with abdominal pain; 76% presented with signs of fetal distress diagnosed by continuous electronic fetal monitoring. Thus abdominal pain is an unreliable sign of complete uterine rupture. There have been no reports of epidural anesthesia delaying the diagnosis of uterine rupture. In the review of 10,967 patients undergoing TOL, there were no maternal deaths and only nine fetal deaths secondary to complete uterine rupture. The literature strongly suggests that epidural anesthesia is safe in TOL even when oxytocin is used for augmentation of labor.