Science & Sensibility

I am impressed and surprisingly moved by this video of a NICU evacuation drill at Beth Israel Deaconess Medical Center in Boston. Drills like these are so important for patient safety.

As the hospital CEO points out in his blog, there is a “dearth of literature on NICU evacuations”. The same is almost certainly true for labor and birth, in which evacuating hospitals means telling at least some women to give birth at home. Other potential disasters, such as prolonged loss of electricity, can mean access to anesthesia and surgical care is rationed severely, or not available at all. And of course more widespread disasters such as pandemics, natural disasters, or terrorist attacks might mean that a labor and delivery unit is closed indefinitely.

In 2006, Lisa Summers wrote about representing the American College of Nurse-Midwives (ACNM) at a government meeting discussing healthcare system preparedness for pandemic flu. In an article in ACNM’s newsletter, she shared:

They are planning for three levels of care. There are pamphlets to educate the public about how to provide appropriate home care that will meet the needs of most flu victims (hydration, isolation, comfort measures); they are working with local hospitals to assess surge capacity and their ability to meet the needs of the sickest (perhaps ventilator dependent) victims; and they are designating places such as hotel ballrooms and convention centers (places with adequate bathroom and food facilities) to be used as influenza care centers for those too sick for home care but not in need of (or who cannot be accomodated in) limited hospital beds.

Summers goes on to ask, given that one-quarter of hospitalized people are childbearing women, and pregnant women and newborns may be among the most vulnerable populations to flu infection, “What plans are being made to determine the best level of care for childbearing women? Will the influenza care centers be appropriate places to give birth?” She provides two compelling reasons that midwives should be front-and-center in efforts to address these questions:

The fact that midwives are experts in normal birth – that we are comfortable and skilled at attending a birth outside of a standard delivery room and without an OR down that hall – makes us uniquely well prepared to care for childbearing women in a disaster situation…The other important skill that midwives have honed well is that of triage of childbearing women – knowing which women are likely to safely give birth without medical intervention, and which women need IVs and an OR.

She also points out that all hazards preparedness should involve educating the public about safe home birth and assessing the surge capacity of birth centers.

In addition to Summers’ article, the ACNM also offers a number of other resources on All Hazards Preparedness, including a handout for women who may be vulnerable to giving birth unexpectedly remote from a skilled provider or prepared birth setting. (Whether it’s because of a terrorist attack or the epidemic of roadside births due to the closure of community-based maternity units.) The handout notes that childbirth education classes and prenatal breastfeeding education, along with infant CPR classes, are essential to preparedness, and gives step-by-step instructions for supporting a woman to give birth at home, including how to handle the most common complications.

I’d love to know, what are the hospitals in your communities doing to prepare labor and delivery units for events such as fires, floods, and loss of electricity? Does anyone have a video of an L&D drill similar to the NICU drill from BIDMC? And how are your health departments preparing for disasters that render hospitals unsafe or inaccessible for childbearing women? How many of my readers have contacted their health departments to offer assistance for childbearing women and newborns in disasters?  (Confession: although I’ve been meaning to for ages, I haven’t!)  Do any of you teach about disaster preparedness in prenatal classes?

Amy Romano Uncategorized childbirth education, hospitals, maternity care systems, safety

[Editor's note: This is a guest post from former Lamaze International President, Jeannette Crenshaw. When Jeannette told me about the video she reviews in this post, I knew I wanted to highlight it as part of the Sixth Healthy Birth Blog Carnival.

I recall  one birth I attended as a midwife, I had to negotiate with the nurse about how long we would "let" the mother and baby remain in skin-to-skin contact after birth. Her reason for wanting to disrupt skin-to-skin time? "I have to put the baby in the computer." Her job (completing birth documentation) was interfering with her job (safeguarding the health and wellbeing of the mother and baby).

Hospital routines are the #1 reason mothers and babies are denied skin-to-skin contact after birth. Changing this  harmful practice is possible, but it takes a commitment to quality and systems improvement.  Now that the Joint Commission is measuring hospital perinatal quality by the proportion of babies exclusively breastfed at discharge,  hospitals need concrete tools to retrain staff and change delivery room culture. Hospitals: it seems like this video may be $39.00 well spent. - AMR]

Skin to Skin in the First Hour After Birth:
Practical Advice for Staff After Vaginal and Cesarean Birth (DVD)

Executive producer and videographer: Kajsa Brimdyr, PhD, CLC; executive and content producers: Kristin Svensson, RN, PhD (cand.) and Ann-Marie Widström, PhD, RN, MTD.
$39.00 at Healthy Children

A new DVD from Healthy Children Project should be mandatory viewing for every labor and delivery nurse and birth attendant. It will help maternity health professionals in hospital settings to implement the best practice of uninterrupted skin to skin care beginning immediately after birth until after the first feeding. This is a “how to” DVD, with the practical advice health professionals need to provide clinical care to mothers and babies who are skin to skin immediately after a vaginal or cesarean birth.

The 40 minute DVD, set to original music by J. Hagenbuckle, has 3 content sections, and a section with a complete list of references. The first section describes the short and long term benefits of skin to skin care for newborns and mothers. It shows the 9 stages healthy newborns experience while skin to skin during the first hour after birth—from the birth cry (stage 1), through suckling (stage 8), and sleep (stage 9). The narrator emphasizes the individual way each baby moves through the 9 stages.

The second section shows how to provide care for mothers and babies while they are skin to skin, after a vaginal, and the third, after a cesarean birth. Both sections begin with health professionals teaching pregnant women about immediate skin to skin care prenatally, and on admission to the hospital—which “sets the stage” for immediate skin to skin contact as a normal part of the birth process. After the vaginal birth, the clinician immediately places the baby on mom’s abdomen. After the cesarean birth, the nurse immediately places the baby on mom’s chest, above the sterile field and drapes, as the doctor continues the surgery and the anesthesiologist monitors the mother. The baby’s father is at mom’s side in both segments. Nurses remove birth fluids as they dry the baby—delicately addressing the common concern that babies should first be “cleaned up” at a warmer. Nurses remove wet blankets, place the baby skin to skin, and cover mom and her baby with warmed blankets. Both sections show competent nurses assessing the newborn, providing care, and supporting the mother and baby as the baby moves through the 9 stages of skin to skin.

I strongly recommend this DVD (only $39.00) for staff in any maternity setting. Childbirth educators will find the first section of the DVD a great addition to their prenatal childbirth and breastfeeding classes (although Breastfeeding—A Baby’s Choice, 2007, may be a better choice). Staff who are working to help their hospitals achieve Baby-Friendly designation will find this DVD useful for training. The narrator uses, for the most part, simple and non-clinical language and the video of mothers and babies will quickly engage the viewer. The DVD’s producers met their objective: “to assist staff in providing behaviorally appropriate, individualized, baby adapted care for the full term newborn using the best practice of skin to skin contact in the first hour after birth”.

Reference:

Healthy Children Project. (Producer). (2007). Breastfeeding—A Baby’s Choice [DVD]. Available from http://www.healthychildren.cc/

Jeannette Crenshaw, MSN, RN, NEA-BC, IBCLC, LCCE, FACCE is a member of the graduate faculty at the University of Texas at Arlington College of Nursing and a family educator at Texas Health Presbyterian Hospital Dallas. She represents Lamaze on the United States Breastfeeding Committee (USBC) and coordinates the Lamaze Breastfeeding Support Specialist Program. She has published articles and presented nationally and internationally on a variety of topics, including evidence based maternity care.

Jeannette Crenshaw Uncategorized DVD, Healthy Birth Practices, hospitals, Joint Commission, newborns, no separation, quality improvement, skin-to-skin contact

I have felt a little bit like a slacker blogger lately, but it’s not for lack of thinking and writing about birth. I just wrapped up an article called Social Media, Power, and the Future of VBAC with Hilary Gerber from Mom’s Tinfoil Hat and Desirre Andrews from Preparing for Birth which we submitted to the 50th anniversary “Looking Back – Looking Forward” special issue of Lamaze’s Journal of Perinatal Education. I’ve also been working with Kristen Oganowski from Birthing Beautiful Ideas to coordinate the development of an NIH VBAC Statement Primer for consumers. We have a bunch of brilliant contributors on board and will be launching the primer later this month at Lamaze’s new (very cool!) social networking site for women, Giving Birth with Confidence.

Now the big looming work comes in the form of conference season. And I want you (yes YOU) to help me. I have a love-hate relationship with conferences. Mostly love. I love how much sharing, connecting, and learning happens. I love finding out what old friends and colleagues are up to and meeting the people doing the most interesting, innovative, and important work in the field. But attending (and especially speaking at) a conference is a lot of work, and often disrupts progress in my other (equally if not more important) work. Also, I hate that conferences take me away from my family.

So…I want to make the most of the opportunities these conferences offer. I want to maximize the amount of sharing, connecting, and learning we – collectively – do. And I want to leave these conferences not with tons of new projects and commitments for myself, but with tons of new opportunities for the broader maternity care community (that means YOU) to drive meaningful improvements for women, infants, and families.

Here’s some more about the conferences I’m attending, and how YOU can be part of them.

On June 7 I’ll be at Health 2.0 Goes to Washington.

Um, have I mentioned lately that I think social media is going to transform maternity care? Well I developed this delirious optimism by hanging around (online) with the Participatory Medicine crowd.  I get to actually meet most of them next week!

I first caught on to the Participatory Medicine train when I read a Grand Rounds blog carnival on the theme of “Meaningful Use” almost exactly a year ago. “Meaningful Use” is government speak for the goal of implementing electronic health records (with piles and piles of stimulus money) in a manner that actually improves care. The Participatory Medicine folks are front and center in the conversation, pushing for patient-access to be the defining characteristic of meaningful. It’s all about liberating the mounds of data that will exist in electronic health records and letting innovators, policy-makers, scientists, and – most importantly – patients themselves use that data to improve health.

I have 10 minutes to speak but a whole day to connect and learn.  Here are my questions for you to help me make the most of this opportunity:

1. What do you think are the most innovative ways women are using the internet or social media to have healthier, safer, and more satisfying childbearing experiences?
2. What are the types and sources of maternity care data that you would most like to see become available?
3. What kind of data do you think should be documented in electronic health records during pregnancy, birth, and the postpartum and newborn period? Think outside the box.
4. What do you think would be the most important benefits (and for that matter, risks or drawbacks) of having complete, unhindered, timely access to your maternity care records?
5. What ongoing or forthcoming projects in the maternity care world could use the insights or funds of outside (non-birth-enthusiast) social innovators?

The following week (June 12-16), I’ll be at the American College of Nurse-Midwives Annual Meeting.

I’m only attending ACNM for one day, but traveling with my family for my kids’ first-ever trip to the nation’s capitol.  I’m giving two educational sessions that couldn’t be more different from one another. First, I’m presenting a talk called, “How Not to Get Duped by Obstetric Research” about the importance of thinking critically about evidence, and how honing critical analysis skills can can help midwives practice and advocate for safe and effective care. The other talk is a panel discussion with Amie Newman from RH Reality Check and Mary Murry, CNM, from The Mayo Clinic “Pregnancy Week by Week Blog,” moderated by Melissa Garvey from ACNM’s own Midwife Connection Blog. We’ll be talking about why more midwives should be blogging and how they can get started.  We recorded a really lively discussion about these issues on The Feminist Breeder & Friends Radio Show on International Day of the Midwife – a preview of our ACNM panel – which you can listen to here:

My questions for YOU:

1. What do you think is the optimal role of midwives (specifically certified nurse-midwives and certified-midwives) in blogging and other social media?
2. How can we protect the privacy and dignity of the women and families we serve (and for that matter, the people we work with) when midwives share about our work in social media spaces?
3. What obstetric routines or beliefs would you most like to hear me critically analyze?  I promise to make at least a blog post or two out of my How Not to Get Duped talk. (Actually, what I’ll also do is write parts of the talk from my prior blog posts, so if you have any favorite posts from the archives that you think would make good case studies, please suggest them!)
4. What are the best DC outings to do with a 3 and an almost-6 year old?

Lastly but Oh-So-Not-Leastly, I’ll be attending the Normal Labour and Birth 5th International Research Conference in July.

I’m not speaking at this conference. I’m going for the sole purpose of blogging it! I wrote a proposal to the conference organizers suggesting that they let me attend and help disseminate the proceedings. They agreed!  I think this is a huge opportunity to learn from the people doing the research about how to optimize the health and safety of healthy women and their babies around the time of birth. We’ll also hear from leaders who are creating and maintaining integrated, midwife-led primary maternity care systems, the gold standard for achieving “woman-centered, safe, effective, timely, efficient, and equitable” care.

What happened when bloggers and other connected consumers attended the NIH Consensus Development Conference on VBAC was astounding and continues to deliver. Since that experience, I’m addicted to putting scientific findings in the hands of engaged, connected consumers, because, as Kay Dickerson from the Cochrane Collaboration says, “We’ll only get evidence-based healthcare in this country through consumer activism.” Today activists have more access than ever before to information and are getting increasingly social media savvy. There’s no telling what we can do if we put our innovative, passionate minds to it and work collaboratively.

So here’s what I want to know from YOU:

1. Whose research are you most interested in hearing about? (Look over the Normal Labour and Birth agenda to see who will be presenting about what.)
2. Would you rather have a little bit of information/analysis about more of the presentations or more in-depth analysis of fewer presentations?
3. Are there any researchers you would like me to conduct a “Consider the Source” Interview with?

Finally, any readers who are planning to attend any of these conferences – I invite you to submit a guest post. I’d love to share multiple perspectives (not to mention the tremendous work of blogging all of these meetings!) Just email me at amyromano [at] Lamaze [dot] org.

Amy Romano Uncategorized ACNM, announcements, cesarean, childbirth education, Healthy Birth Practices, hospitals, interventions, maternity care systems, media, midwives, NIH Consensus Conference, Normal Labour & Birth Conference, Participatory Medicine, Personal Health Records, safety

The Institute for Healthcare Improvement (IHI), the leading nonprofit organization working to accelerate change in healthcare, has been in the news this month because its CEO, Donald Berwick, was recently nominated to head up the Centers for Medicare and Medicaid Services. (For those not familiar with Berwick, read his phenomenal article, “What ‘Patient-Centered’ Should Mean: Confessions of an Extremist“). Berwick himself and IHI’s Managing Director, Sue Gullo, RN, were key players in the recent Transforming Maternity Care Project coordinated by Childbirth Connection. Now, the IHI is rolling out programs to help hospitals and health care systems implement some of the work put forth in the project’s Blueprint for Action. These initiatives also coincide with the new Joint Commission perinatal core measures which hospitals may implement as of this month. Here’s what is on offer so far:

• Earlier this month, IHI recorded Momentum for Maternity of the Safest Kind, a podcast with the Transforming Maternity Care leadership about trends in health care for pregnant women, new mothers, and newborns and the work needed to reliably provide safe and effective care, reduce disparities, and rein in costs.
• On Tuesday, May 4 from 3-4 PM ET, Sue Gullo will host a public call to discuss the IHI’s work on improving safety in second-stage labor. The call can be accessed through the IHI Webex System (Click on Improving Perinatal Care Collaborative Info Call) or via land line at 866-469-3239 (enter the session ID 354 952 217*. More information can be found on IHI’s Improving Perinatal Care page.
• A series of seven web-based sessions for hospital staff involved in quality improvement efforts will focus on the safe use of oxytocin for induction, starting with avoiding all elective deliveries before 39 weeks. The series begins May 14.

To keep up with other IHI offerings, you can follow them on Facebook or Twitter

Amy Romano Uncategorized announcements, hospitals, induction, interventions, maternity care systems, safety, second stage

First the good news: based on the presenters, it looks like the NIH VBAC conference will be a great improvement over the elective cesarean surgery travesty of four years ago. The conference seems likely to provide solid, evidence-based information on for whom and under what circumstances VBAC is safest and most likely to end in vaginal birth. Objective, unbiased information on these points is sorely needed, as illustrated by this 2008 response by ACOG vice president Dr. Ralph Hale, who one would expect to know better, to a plea to make VBAC more available:

VBAC is potentially an extremely dangerous procedure for both mother and infant. Although 98% of women can potentially have a successful VBAC, in two percent of cases the result can be a rupture of the old scar. If this happens, then death of the baby is almost certain and death of the mother is probable. Even if the mother does not die, virtually 100% will lose their child bearing ability. To prevent these disasters, the ability to perform immediate surgery is critical.

In point of fact, with appropriate care the scar rupture rate can be 0.5% or less (6,13,15), not 2%, and the chance of the baby dying as a result of scar rupture is 5% (9), not “almost certain.” As for the mother, women rarely die or have hysterectomies, but both are more common with elective repeat cesarean than planned VBAC (3,17,18,19).

Before we break out the champagne, though, consider this: nowhere in the program is any acknowledgement of a patient’s fundamental right to refuse surgery. Quite the opposite. The background statement is rife with the language of doctors giving (or withholding) permission:

For most of the 20th century, once a woman had undergone a cesarean . . ., many clinicians believed that all of her future pregnancies required delivery by cesarean as well. However, in 1980 a National Institutes of Health Consensus Development Conference panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered.

Even more telling, VBAC is positioned as a patient and provider “preference.” The background section uses this term as does the title of the session on obstetric decision making, and Anne Lyerly, the obstetrician speaker on VBAC ethics, is co-author of the commentary “Mode of delivery: toward responsible inclusion of patient preferences.”

The problem with patient preference is that it is readily trumped by provider preference. If VBAC is no more than a menu option, the danger in determining who makes a good candidate and what constitutes optimal circumstances for VBAC is that it legitimizes its opposite: doctors and institutions denying VBAC to women they don’t think make the cut or where they don’t think safety for VBAC is adequate. (The latter, BTW, is spurious. Emergencies occur in non VBAC labors. If a hospital isn’t safe for a VBAC labor, then it isn’t safe for any woman to labor there. Not to mention that ACOG guidelines for labor induction and American Society of Anesthesiologist guidelines for epidurals require the ability to perform an urgent cesarean because of the potential for just such emergencies, but no one is setting strictures on these procedures [1,2].)

A secondary danger of the “preference” perspective is that conference presenters may treat non-clinical factors such as “medico-legal concerns” and “economic considerations” as valid reasons for VBAC refusal instead of obstacles that must be overcome. This would leave us where we are now with obstetricians and hospitals free to do as they choose, and what they choose is no VBACs. A 2005 survey found that more than half the women wanting a VBAC were denied that option, a 2009 survey of 2850 hospitals revealed that half of them had a ban or de facto ban against VBAC, and Lord knows we do not need any more stories like Joy Szabo’s.

To give the conference planners and presenters their due, normally, it makes perfect sense to limit procedures to those with the skill to perform them and require their performance in environments with adequate resources. It makes sense as well as to allow providers and institutions to decline performing them. But VBAC is the exception because it is not a procedure. Labor is what inevitably happens at the end of pregnancy. Refusing VBAC means forcing women to agree to major surgery they neither want nor need in order to obtain medical care.

Depriving a woman of choice on grounds of the baby’s safety, the primary clinical rationale for VBAC denial, values the child over the mother. This is not hyperbole. According to studies of a large U.S. population, the maternal risk of death (3 per 10,000) with elective repeat cesarean is in the same ballpark with the risk of the baby dying subsequent to scar rupture during a VBAC labor (1 per 10,000) (13,19). Moreover, as the conference will discuss, a woman undergoing repeat cesarean not only runs the risks of that surgery, but an increasing risk of placental attachment abnormalities in any future pregnancies as she accumulates surgeries, abnormalities that threaten both her life and that of the fetus. By contrast, once a woman has a VBAC, she will almost always continue to have uneventful VBACs in future pregnancies. VBAC denial is the sole instance where doctors feel justified in compelling one person to undergo a medical procedure to benefit another party, but no ethical principle or law allows this, including when the beneficiary will otherwise surely die, which is far from the case with VBAC.

Failure to recognize that VBAC is a right has another consequence as well. If you start from this premise, it follows that a key question will be how best to promote safe vaginal birth in women desiring VBAC, but this is missing from the agenda. My researches for the VBAC chapter of the new edition of Obstetric Myths turned up much food for thought on this issue. For example, a study on the large U.S. population mentioned above reported scar rupture rates of 9 per 1000 with labor augmentation and 10 per 1000 with induction but only 4 per 1000 in women laboring spontaneously (13). If every woman had labored without stimulation, 63 women would have had scar ruptures instead of 124. On the other hand, a study reported equally low scar rupture rates in induced labors (3 per 1000) as in labors with spontaneous onset (16), which suggests that while spontaneous labor is optimal, women who truly require induction can be induced without excess risk provided clinicians pay proper attention to patient selection and induction protocol. Research also shows that physiologic care substantially increases VBAC rate and reduces scar rupture rate (15). The birth center VBAC study reported a VBAC rate of 81% in women with no prior vaginal birth, 9 to 20 more women per 100 than among similar women in nine studies (4,5,7,8,10-12,14,20) who had conventional obstetric management. The scar rupture rate overall was a mere 2 per 1000.

We rightly should applaud any effort that helps women and clinicians decide between planned VBAC or repeat cesarean but lament any attempt to curtail a woman’s right to refuse surgery, be it on clinical or nonclinical grounds. VBAC is a right, not a preference, a right, let me add, not abrogated by the clinician’s opinion of its wisdom. It does not matter if you, me, and everyone on the planet were to line up and say to a woman VBAC is a bad idea in your case, she still has the right to say “no” to surgery. Clinicians and institutions must be brought to accept their ethical and professional obligation to provide best practice care to every woman wanting planned VBAC. If the conference fails in this task, then whatever it accomplishes, it will fall short of its duty to childbearing women with previous cesareans.

1. ACOG. Induction of labor. ACOG Practice Bulletin No 107 2009.

2. ASA. Guidelines for regional anesthesia in obstetrics. 2007. (Accessed 2/12/2010, at http://www.asahq.org/publicationsAndServices/standards/45.pdf.)

3. Blanchette H, Blanchette M, McCabe J, et al. Is vaginal birth after cesarean safe? Experience at a community hospital. Am J Obstet Gynecol 2001;184(7):1478-84; discussion 84-7.

4. Cahill AG, Stamilio DM, Odibo AO, et al. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol 2006;195(4):1143-7.

5. Caughey AB, Shipp TD, Repke JT, et al. Trial of labor after cesarean delivery: the effect of previous vaginal delivery. Am J Obstet Gynecol 1998;179(4):938-41.

6. Chauhan SP, Martin JN, Jr., Henrichs CE, et al. Maternal and perinatal complications with uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: A review of the literature. Am J Obstet Gynecol 2003;189(2):408-17.

7. Gonen R, Barak S, Nissenblat V, et al. The outcome and cumulative morbidity associated with the second and third postcesarean delivery. Am J Perinatol 2007;24(8):483-6.

8. Goodall PT, Ahn JT, Chapa JB, et al. Obesity as a risk factor for failed trial of labor in patients with previous cesarean delivery. Am J Obstet Gynecol 2005;192(5):1423-6.

9. Guise JM, McDonagh M, Hashima JN, et al. Vaginal birth after cesarean (VBAC) Report/Technology Assessment No. 71. Rockville, MD: Agency for Healthcare Research and Quality; 2003 March 2003. Report No.: AHRQ Publication No. 03-E018.

10. Gyamfi C, Juhasz G, Gyamfi P, et al. Increased success of trial of labor after previous vaginal birth after cesarean. Obstet Gynecol 2004;104(4):715-9.

11. Hendler I, Bujold E. Effect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes in women undergoing trial of labor. Obstet Gynecol 2004;104(2):273-7.

12. Kwee A, Bots ML, Visser GH, et al. Obstetric management and outcome of pregnancy in women with a history of caesarean section in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2007;132(2):171-6.

13. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351(25):2581-9.

14. Landon MB, Leindecker S, Spong CY, et al. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 2005;193(3 Pt 2):1016-23.

15. Lieberman E, Ernst EK, Rooks JP, et al. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol 2004;104(5 Pt 1):933-42.

16. Locatelli A, Regalia AL, Ghidini A, et al. Risks of induction of labour in women with a uterine scar from previous low transverse caesarean section. BJOG 2004;111(12):1394-9.

17. Loebel G, Zelop CM, Egan JF, et al. Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital. J Matern Fetal Neonatal Med 2004;15(4):243-6.

18. McMahon MJ, Luther ER, Bowes WA, Jr., et al. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996;335(10):689-95.

19. Spong CY, Landon MB, Gilbert S, et al. Risk of uterine rupture and adverse perinatal outcome at term after cesarean delivery. Obstet Gynecol 2007;110(4):801-7.

20. Turner MJ, Agnew G, Langan H. Uterine rupture and labour after a previous low transverse caesarean section. BJOG 2006;113(6):729-32.

Henci Goer Uncategorized cesarean, childbirth education, hospitals, NIH Consensus Conference, VBAC