Science & Sensibility

April is Cesarean Awareness Month (CAM) and that presents a wonderful opportunity to share resources for cesarean prevention and recovery as well as Vaginal Birth after Cesarean (VBAC) support.

I am a co-leader of the Seattle chapter of the International Cesarean Awareness Network (ICAN) and teach classes in Seattle on both VBAC and Cesarean birth. (I call them VBAC YOUR Way and Cesarean YOUR Way)  I thought I might share my favorite resources on this topic and ask you to share with readers what you prefer to share with your students, patients and clients on this topic.

ACOG Committee Opinion on Cesarean Delivery on Maternal Request

ACOG Practice Bulletin on Vaginal Birth after Cesarean Delivery

Birthing Beautiful Ideas; VBAC Scare Tactics – Kristen Oganowski has a great series on scare tactics that women hoping to VBAC might face.  Good balance of heart and science.

Birthing Normally after A Cesarean or Two – Science & Sensibility three part interview with author and childbirth researcher Hélène Vadeboncoeur, done by Kimmelin Hull, former Science & Sensibility Community Manager

Cesareanrates.com - organized by Jill Arnold (of The Unnecessarean), provides a comprehensive breakdown of cesarean rates by state and hospital for the USA.

Childbirth Connection – Vaginal Birth or Repeat C Section: What You Need to Know

Evidence Based Birth – Rebecca Dekker is a Science & Sensibility contributor and writes a great fact based blog.  She frequently writes on the topic of cesareans.

Giving Birth With Confidence’s A Woman’s Guide to VBAC: Navigating the NIH VBAC Recommendations - Lamaze International’s parent blog hosts this wonderful resource written by Amy Romano and Kristen Oganowski

International Cesarean Awareness Network – international organization that works to prevent unneeded cesareans, promote cesarean recover and help women striving for a VBAC. Offers both online support as well as local chapter meetings.

A Natural Cesarean – A Woman Centered Technique. This video demonstrates and discusses ways that health care providers can make the cesarean more mother-baby centric, offering techniques that provide a great degree of satisfaction to the birthing woman.

NIH VBAC Consensus Statement – In 2010,  the National Institute of Health, a US government agency convened experts on VBAC and Cesareans and took testimony and heard discussions about best practice.  They summarized the results of this groundbreaking forum in this document.

The Truth about Cesareans – by Eugene Declercq.  Short 6 minute video on why the cesarean rate might be so high.

VBACFacts.com – A blog run by Jen Kamel, this website is a wealth of information and analysis on current studies and data as it relates to cesareans and VBAC birth.  Jen also runs a fabulous VBAC webinar that is available online.

The Well-Rounded Mama – blog run by occasional Science & Sensibility contributor Pamela Vireday, provides frequent information on VBACs, cesareans and large sized women, but the insight is valuable for all.

I am also aware of a free webinar, for birth professionals and providers as well as parents, “Family Centered Cesarean Birth” that you may want to consider signing up for.  Click here for more information. The webinar is presented live on Thursday, April 11th and then available after the presentation to watch as a recording.

What are your favorite go to resources to share with expectant parents?  Do you have a particular film clip that you like to show?  A book recommendation?  Do you have an effective method of presenting information on Cesareans and VBACs in your classes and with your clients and patients.  Let’s have a discussion in the comments section.  I welcome your thoughts.

Sharon Muza ACOG, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Maternal Quality Improvement, Maternity Care, Vaginal Birth After Cesarean (VBAC) CAM, Cesarean Awareness Month, cesareans, Childbirth Connection, Childbirth Education, Giving Birth With Confidence, ICAN, VBAC

Regular contributor Penny Simkin shares her experiences with parents who sing to their baby in utero and then continue after birth and looks at what the research says about this practice in this two part blog piece.  Part two can be found here. Join me in reading about some unique situations that Penny shares as she explores this opportunity for parents to bond with their unborn child.  - Sharon Muza, Science & Sensibility Community Manager.

_________________

People have sung to their babies forever. Every culture has lullabies and children’s songs that are passed down through the generations. New ones are written and shared and the custom goes on –a rich part of the fabric of human civilization. These songs are designed to relax babies, calm their fears, or entertain and amuse them throughout childhood. As we have learned more about the life and capabilities of the fetus, we have realized that the fetus can hear clearly for months before birth, and also can discriminate sounds and develop preferences for some sounds over others. Furthermore, at birth, newborns respond to familiar sounds by becoming calm and orienting toward the source of the sound, and even indicate their preferences for familiar voices and words over the unfamiliar.

Newborn babies prefer their parents’ and other familiar voices over those of strangers (1), and they prefer hearing a story that their mother had read frequently in utero rather than an unfamiliar story or the familiar one read by someone other than their mother (2).  Fetuses hear, remember, have preferences, respond to, and discriminate among differences — in sounds, music, voices.

These exciting findings have inspired educators to advocate prenatal learning through recordings played through a mother’s abdomen (of languages, music, and other things). They have inspired birth activists and baby advocates to provide a safe enriching environment for the fetus. Advocates of prenatal bonding emphasize communication between parent and unborn child as a powerful way to strengthen the bond.

I’d like to offer my take on this phenomenon and urge everyone who works with expectant parents to tell them about some unique and heart-warming benefits of singing or reciting rhymes to their unborn babies.

I think my interest in parents singing to their babies prenatally began in the 1980s when I first read Michel Odent’s book, “Birth Reborn”(3). Odent is a French physician who has always been ahead of his time. He had a unique and original maternity care program at his hospital in Pithiviers, France. His book had a great influence on my understanding of normal birth, and the book is still worth reading today, along with all his subsequent ones. One lovely aspect of his program is particularly relevant to the topic of this blog post. The program included a weekly singing group at the hospital, attended by pregnant women, their partners, families with young babies, the midwives, and Odent himself. The group was led by an opera singer who believed singing to be important for fetuses, babies and those who care for them. Odent’s account inspired me to invite Jamie Shilling, a folk singer who had recently taken my birth class, to bring her guitar and her baby to my classes a half hour early each week and sing with the expectant parents. That went on very successfully for several class series, then the groups decided to combine and carry on in a monthly sing- along for expectant parents and new families, in a private home –Although the groups  eventually disbanded, they provided many parents with opportunities to sing together and connect with their babies and each other in relaxing and peaceful surroundings. A high point during that time was when Michel Odent came to Seattle to give a conference and he agreed to come to one of our sing-alongs. See the photo of Jamie leading the group of expectant and new parents, with Michel Odent and myself participating. He taught us the song, “Little Black Cat” in French.

© Penny Simkin

I couldn’t help but think during those times, how the unborn and new babies must love hearing their parents singing. Seeing the parents caressing the mother’s belly as they sang was heartwarming. That happened  in the mid- 1980s, when much research on the capabilities of the unborn and newborn baby was beginning to be published. Recalling those special gatherings, I have always suggested to my students in childbirth class that they sing to their unborn babies, or play their favorite recorded music, with the thought that the baby will remember it and be soothed by it after birth.

But it was one couple, whom I served as a birth doula, who took my suggestion to another level, and showed me much more about the value of singing to the unborn baby. They were having their second child, hoping for a VBAC. When they discovered that they were having a boy, they decided to give their baby the song, “Here Comes the Sun” and sang it to him often during pregnancy. The VBAC was not possible, and as the cesarean was underway, and the baby boy, crying lustily, was raised for the parents to see, the father began belting out the baby’s song. Though the mother didn’t have a strong voice under the circumstances, she also sang. The baby turned his head, turned his face right toward his father and calmed down while his father sang. Time stopped. As I looked around the operating room, I saw tears appear on the surgical masks.

It’s a moment I’ll never forget, and it was that event that taught me the value, not only of singing prenatally, but also, singing the same song every day. Not only does the baby hear his or her parents’ voices, not only does he or she hear music, but the baby also gets to know one song very well. Familiarity adds another feature to this concept, because we know that fetuses have memory and prefer the familiar. Think for a moment about what this might have meant to our cesarean-born baby –suddenly being removed from the warmth, wetness, and dimness of the womb with its mother’s reassuring heartbeat, into the cold bright noisy operating room. The baby’s transition to extrauterine life is hectic and full of new sensations. He cries reflexively, but perhaps also out of shock and discomfort. Then he hears something familiar – voices and music and the sounds of words that he has heard many times before – something he likes. He calms down, and seeks the source of this familiar song. Everyone present is moved by this gift to the baby from his parents.

I’ve become passionate about this idea as a way to enhance bonding between parents and babies, but also as a unique and very practical measure for soothing a fussing baby or a sick baby who can’t be held or breastfed. Please join me on Thursday, for Part Two on this topic when I will continue the discussion including research evidence that supports this concept: practical suggetions for childbirth professionals to share with expectant parents; and some very endearing film clips of families singing to their babies.

References:

1. Brazelton B. Cramer B. (1991)The Earliest Relationship: Parents, Infants, and The Drama Of Early Attachment . Da Capo Press Cambridge, MA.

2. De Casper A. 1974, as described in Klaus M, Klaus P, Kennell J. 2000. Your Amazing Newborn. Da Capo Press, Cambridge, MA.

3. Odent M. 1984, Birth Reborn. Pantheon Books: New York 

Penny Simkin Cesarean Birth, Childbirth Education, Doula Care, Guest Posts, Infant Attachment, Newborns, Parenting an Infant, Vaginal Birth After Cesarean (VBAC) Childbirth Education, Infant Attachment, Michel Odent, newborns, Penny Simkin, perinatal bonding, Singing to baby

We wrap up Cesarean Awareness Month and acknowledge the week of International Midwifery Day with a post about an initiative to  create a VBAC Friendly Hospital, led by midwives.

ln honor of Cesarean Awareness Month, Lakeisha Dennis, the Chapter Leader of International Cesarean Awareness Network (ICAN) of Greater Essex County, New Jersey, invited Elaine Diegman, CNM, Ph.D, to speak about Worst to First, a talk about how to modify New Jersey’s high cesarean rate. Professor Diegman is head of the University of Medicine and Dentistry of New Jersey’s (UMDNJ) School of Nursing’s Midwifery Program.

Nationwide, the cesarean section rate is about 33%; in other words, one in three women in the United States give birth by surgical cesarean section. The cesarean section rate has risen about 50% in 15 years. According to the World Health Organization, a cesarean section rate of about 5 – 10% is the target for overall optimal maternal – baby outcome.

The state of New Jersey has a cesarean section rate of about 39%. New Jersey consistently places in the top two states for the highest cesarean section rate, sharing this distinction at the moment with the state of Louisiana.

Despite the National Institute of Health’s recommendation about vaginal brith after cesarean (VBAC) being safe under certain circumstances, there is a ourtright ban on vaginal birth after cesarean (VBAC) in many hospitals across the nation and the birth educators and doulas at this meeting said they noticed some ob-gyn practices have a quiet bait and switch tactic in place around this issue.

Professor Diegman has a long and distinguished career. She started out by telling us she’s actually the oldest practicing midwife in New Jersey (and maybe in the American College of Nurse Midwives). She gave us some history about the profession of midwifery. She reminded us midwifery is mentioned in the Bible and all the past royal houses of Europe used midwives for their births. She added she attended so many births in her career, she stopped counting after 3000.

Professor Diegman wanted to talk to us about pro-active change regarding lowering the cesarean section rate. UMDNJK has spearheaded a new initiative at Newark Beth Israel Hospital. UMDNJ has worked to become an official Vaginal Birth After Cesarean (VBAC) Center, keeping with the guidelines developed by the National Institutes of Health and the New Jersey Hospital Association. Dr. Diegman and Mary Markowsky, CNM, who heads the midwifery area of Newark Beth Israel, were instrumental in helping the hospital gain this distinction.

The empowering role of the childbirth educator

Professor Diegman stressed it is crucial we educate women about the normalcy of birth. She is passionate about the midwifery model of birthing. She wants to spread the word about how pain in childbirth is not like pain in illness, and emphasizes women do have the ability to rise to the experience of childbirth.

She emphasized the crucial role of education in preserving a woman-baby-centered birth culture. Professor Diegman said healthcare providers don’t normalize birth for women and don’t introduce women to nonpharmacological techniques to manage their birth.

Women only learn these techniques in independent childbirth education classes. So, the role of the childbirth educator is crucial in helping women understand what birth really can be and in getting our women back. The childbirth educator has a unique role to educate and empower women.

Dr. Diegman said the media and our constant exposure to technology has eroded women’s confidence in their ability to give birth. She wants to bring our women back. When Oprah, a powerful media presence, comes out positively about epidurals, that hugely influences our society’s views of birth. Dr. Diegman went on to say Oprah’s not the only one; there’s a constant flow of negative media stereotypes about birth. In addition, she said our constant reliance on technology has eroded our confidence in our bodies. She said “We need to be warriors and get our women back!”

Sonora Davis, community doula with the Hudson Perinatal Consortium, says “….women don’t seem to be taking the time to acknowledge their pregnancy or bond with their babies in utero.” She said she’s noticed this leads to a lack of focus on the birth. The other doulas, childbirth educators and midwives in the room echoed this concern, saying the disconnect during pregnancy sets up a disconnect to the experience in the birth room.

Childbirth educators play a crucial role in helping women know what their options are for birth, showing them what normal physiological birth looks like, and helping them focus on their pregnancy and the miracle of becoming a mother.

It is indeed good news that there appears to be a small upswing in one corner of the world back to women-baby-centered birth. As childbirth educators we can help women learn their options for women-baby-centered birth.

We need to keep asking, as Beverly Chalmers did in her editorial in Birth (2002):

How Often Must We Ask for Sensitive Care Before We Get It? 

References

Chalmers, B. (2002).How often must we ask for sensitive care before we get it? Birth, 29(2), 79-82.

 I wish to acknowledge Jill Wodnick, MS, in helping collate the information in this article.

Kathy Morelli Cesarean Birth, Childbirth Education, Uncategorized, Vaginal Birth After Cesarean (VBAC) Cesarean Awareness Month, Cesarean Birth, VBAC

All pregnant women deserve to have access to compassionate, evidence-based maternity care which inherently supports the normalcy of labor and birth—and remains poised to effectively handle the occasional circumstance when birth strays from normal.  They deserve to be cared for by well-trained midwives, family physicians or obstetricians–depending on their particular situation and which type of care is most warranted–who work together seamlessly as a congruent maternity care team.  They deserve to be cared for by maternity care professionals who trust each others’ skills and resist the urge to question each others’ motives.  Expectant families deserve to remain center stage throughout their pregnancies, labors and births—avoiding being lost in the cacophony of politics that so often suffocates the system and obscures the practice of pure, evidence-based care.

Last weekend, Dr. Brian Goldman introduced his CBC Radio audience to this very scenario, during his show, White Coat, Black Art.  During the show “Dr. Brian,” who is both an emergency department physician in Toronto, and a medical journalist, takes listeners to Nelson, B.C., Canada, where he follows obstetrician Shiraz “Raz” Moola and registered midwife Ilene Bell who both work at Kootenay Lake Hospital.

Only minutes into the radio show, it becomes clear: expectant families delivering at Kootenay Lake Hospital are the beneficiaries of a truly integrated maternity care team where family physicians and midwives handle the majority of deliveries, leaving the complicated scenarios to obstetricians.  This is despite Canada’s fee for service medical system in which, “an obstetrician uses the fees he or she earns from doing easy deliveries to offset or subsidize the more time-consuming and more stressful deliveries that require additional skill and experience.”

During the course of the radio show, scenarios in which obstetricians are called in for deliveries are described.   Despite what sometimes feels like a disbelief in the humanity of obstetricians that some normal birth advocates imply, this radio show does an excellent job of pictorializing  the “why” behind the impetus to medicalize labor and birth.  During the interview, Dr. Moola describes a scenario in which he could palpate a fetus inside it’s mothers abdominal cavity—but outside the womb—following a cesarean scar rupture during an attempted VBAC.  Carrying around past experiences like this can prompt a level of caution—even if not evidence-based caution—as the human side of a physician hopes to avoid dealing with such a circumstance in the future.  And yet, the maternity care providers interviewed in Dr. Goldman’s story don’t seem to allow those past experiences—as few or frequent as they may be—to prompt a technocratic approach to their maternity care services.

“Our training is to promote the normal,”  says Ilene Bell.  “We want to normalize.”

In fact, the radio show audibly follows the progress of a VBAC candidate through parts of her labor and successful delivery, attended by  Bell.

“At one level, we all think we can do it the best,” says Dr. Moola.  But he goes on to describe how the “best” (maternity care provider) is most often a midwife or family physician, and only sometimes an obstetrician.

I highly recommend listening to the whole radio show, and forwarding the link onto your colleagues.  After listening, please come back here and answer the following questions:

1.  What elements of the maternity care partnership described in this show does my local birth community already harbor?
2. What elements of the maternity care partnership described in this show can my local birth community/hospital learn from?
3. What are three steps I can take in my community to encourage this type of partnership approach to maternity care?

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Kimmelin Hull Evidence Based Medicine, Science & Sensibility, Uncategorized, Vaginal Birth After Cesarean (VBAC) Black Art, collaborative maternity care, Dr. Brian Goldman, Ilene Bell, Kootenay Lake Hospital, MD, midwife, Shiraz Moola, VBAC, White Coat

[Editor's note:  This article by Amy Romano was originally posted on Childbirth Connection's Transforming Maternity Care site, September 12, 2011 and is re-purposed with permission.]

When I recently updated Childbirth Connection’s VBAC or Repeat C-Section Topic to reflect the findings of a government-sponsored systematic review and national consensus recommendations, I was struck by how few of the facts have changed in the years since the government’s previous VBAC evidence report. While there are more data than before, we already knew that the risks of uterine rupture in labor were about 1 in 200, that accumulating cesareans sharply increases the likelihood of life-threatening complications in future pregnancies, and that there are few situations when planned VBAC is objectively unreasonable. Although the evidence has not abated the precipitous drop in VBACs, perhaps unprecedented national consensus about the importance of prioritizing VBAC services, an increasingly savvy grassroots movement, and urgent calls from obstetric leaders will begin to move the needle.

As we shift the conversation from whether to do VBACs to how to enable more of them, focus on quality and safety in the context of VBAC is long overdue. According to new government statistics (pdf), one in five of the more than 4 million births each year in the United States occur to women who have previously given birth by cesarean. If evidence supports VBAC as a “reasonable option” for most of this population – and indeed the better option for many – it is time to be reasonable about how to make VBAC as safe, accessible, and satisfying as it can possibly be.

In the absence of nationally endorsed quality measures for VBAC, payment reform to provide better incentives to offer and achieve VBAC, and care coordination to help pregnant women navigate the health care system (all urgently needed), we turn to the broader concept of maternity care quality to offer a framework for high-quality VBAC care. We’re interested in hearing what VBAC quality improvement projects exist in your community, and are eager to feature them in our TMC Directory.

A QUALITY FRAMEWORK FOR VBAC

1. Help more women make and implement choices that are informed by the best quality evidence and aligned with their own values and preferences.

Rationale: While much attention has been given to ACOG’s “Level C” recommendation to undertake planned VBAC “in facilities with staff immediately available to provide emergency care,” this recommendation is superseded by their “Level A” recommendation to “counsel women about VBAC and offer [trial of labor]” to appropriate VBAC candidates. In addition, “decision quality,” i.e., the extent to which choices align with a woman’s stated preferences and values and available evidence, is a marker of overall health care quality. Not to mention, honoring people’s informed choices is the legal and ethical standard, acknowledged by all major health care bodies.

Current approach: Few women have a choice at all. According to the VBAC Policy Database, a voluntary monitoring project by the International Cesarean Awareness Network, half of U.S. hospitals either ban VBAC outright or have no providers willing to attend VBACs. In our most recent national Listening to Mothers survey, more than half of women interested in a VBAC were denied the option, usually because of provider refusal or hospital policies. In areas where VBACs are “offered,” women must often meet eligibility criteria that are not supported by high-quality evidence. Informed consent processes typically solicit consent for VBAC but may not provide a special consent process for repeat cesareans, despite the fact that repeat cesareans pose different and in some cases much more serious risks than first cesareans.

Why this is inadequate: Both planned VBAC and planned repeat cesarean section are reasonable choices with important potential benefits and harms but the trade-offs are very different. The current approach, which ostensibly is intended to reduce the already low likelihood of avoidable perinatal death or injury and associated liability, has resulted in significant collateral damage: most notably an increased risk of maternal mortality and a growing prevalence of life-threatening complications for both mothers and babies in future pregnancies. We are also seeing troubling care patterns, including court-ordered repeat cesareans, women laboring in hospital parking lots so they can show up just in time to give birth and avoid the pressure for a cesarean, and a sharp increase in the number of women with prior cesareans choosing to give birth at home, sometimes with no skilled provider present at all. The Agency for Healthcare Research and Quality (AHRQ) team that conducted the 2010 systematic review on VBAC versus routine repeat cesarean referred to the VBAC access issues as “chilling,” an assessment with which we at Childbirth Connection agree.

Another approach: We urgently need evidence-based, field-tested shared decision making tools to communicate the research evidence and help women clarify their preferences and values. We have seen a commitment to this approach in Canada, the United Kingdom, and Australia, but thus far nothing in the U.S. (a situation we hope to change through our Shared Decision Making Maternity Initiative). Although decision support tools can help a woman select the best choice for her, system barriers including payment incentives, liability concerns, and clinician education must be addressed simultaneously to ensure that she can implement her choice. Assessing the potential for shared decision making tools and processes to reduce liability should be a research priority.

2. Maximize the proportion of women planning VBAC who experience uncomplicated vaginal births

Rationale: Morbidity in VBAC labors is concentrated in the subset of women who have unplanned repeat c-sections. These risks include infection, hemorrhage, blood clots and emotional distress. In addition, having a VBAC reduces risks in subsequent pregnancies and virtually ensures that future births will be vaginal, while having a repeat cesarean sharply increases risks in subsequent pregnancies and virtually ensures that future births will be surgical. Finally, repeat cesarean costs payers significantly more than VBAC and has significant downstream economic costs because of these effects in subsequent pregnancies.

Current approach: Clinicians and researchers seem to have responded by focusing on selecting the women most likely to have a vaginal birth. Several researchers have attempted to create prediction tools to select these women, and some clinicians and hospitals have imposed strict eligibility criteria for planned VBAC. Significantly less attention has been given to prenatal and intrapartum interventions and care processes that may enhance a woman’s likelihood of having a safe vaginal birth.

Why this is inadequate: Calculating the likelihood of vaginal birth can provide helpful information to women making an informed choice to plan a VBAC or repeat cesarean. However, even women with a lower-than-average likelihood of vaginal birth usually have a better than 50-50 chance. Moreover, some groups with lower likelihoods of vaginal birth, such as women with high BMI or multiple prior cesareans, also face significantly higher than average likelihood of harm if they end up with a cesarean. The AHRQ systematic review concluded that none of the available prediction tools adequately selected women for successful trial of labor.

Another approach: The AHRQ systematic review researchers emphasized the need to incorporate “non-medical factors” in prediction tools to enhance their usefulness. These factors, which include liability concerns, the nature and extent of informed decision-making, and provider and birth setting characteristics, appear to have a stronger effect on VBAC likelihood than factors intrinsic to the woman. In addition, research is urgently needed to identify labor care strategies to promote safe vaginal birth in women with prior cesareans, in particular the potential contribution of midwives and doulas. A randomized controlled trial examining the impact of doula care on VBAC labors is currently underway in Canada.

3. Provide the best possible response to obstetric emergencies including uterine rupture

Rationale: Uterine rupture occurs in about 4.7 per 1000 VBAC labors and is an obstetric emergency requiring prompt delivery. Although the outcome of uterine rupture is usually favorable for both infants and mothers, morbidity and mortality may be minimized if the team is prepared, communicates well, and responds quickly and in a coordinated fashion.

Current approach: The small chance of a sudden emergency with high risk of serious fetal and maternal harm resulted in ACOG’s recommendation that surgical and anesthesia staff should be “immediately available” for VBAC labors. Although in 2010 ACOG clarified that women should be able to make an informed choice for a VBAC despite this recommendation, or be referred to another facility, the response to the possibility of uterine rupture continues to favor simply prohibiting women from planning VBACs.

Why this is approach is inadequate: The singular focus on availability of a surgical team has created a situation where women in communities without these resources must consent to unwanted and potentially unneeded cesareans in order to access any maternity care at all. It also assumes that availability of surgical resources automatically translates into an optimal outcome, but unprepared or ineffective care teams may not be able to avert preventable poor outcomes despite being “available.” The AHRQ review researchers identified several other obstetric emergencies that occur with similar frequency as uterine rupture and result in similar likelihoods of serious harm but for which the obstetric community does not deem 24/7 cesarean capability to be necessary.  For these obstetric emergencies, rather than forbidding labor, hospitals have begun focusing on proven patient safety strategies like enhancing teamwork, implementing checklists, and conducting drills and simulations.

Another approach: As noted above, obstetric emergencies requiring prompt cesarean delivery can happen in any labor and in any birth setting. The emerging concept of “high reliability obstetrics” provides a framework for preventing adverse events and managing them in a consistent fashion when they occur despite prevention efforts. This requires a multi-disciplinary commitment to preparedness, teamwork, communication, and documentation. Various safety courses teach teamwork and management of emergencies in obstetrics. A systematic review of multi-disciplinary simulation training found that such programs improved knowledge, practical skills, communication, and team performance in acute obstetric situations and were associated with improved neonatal outcome.

BRINGING BACK VBAC

If VBAC is a reasonable option for most women, we need a reasonable approach to ensuring quality and safety in VBAC. Like maternity care generally, transforming VBAC care will take multi-stakeholder commitment to system reform. With so much inertia in the system, consumers and advocates must maintain a strong voice to push for positive change. Our newly updated VBAC or Repeat C-section Topic and the latest data on cesarean and VBAC trends are two resources to help women and their advocates. Our Action Center provides more ideas for engaging in maternity care transformation.

Posted by:  Amy Romano, CNM

Amy Romano Cesarean Birth, Research, Transforming Maternity Care, Vaginal Birth After Cesarean (VBAC) Agency for Healthcare Research and Quality, Amy Romano, Childbirth Connection, Listening to Mothers surveys, VBAC