New ACOG Guidelines: Vaginal Birth After Cesarean is a Safe Option

For Immediate Release
July 27, 2010

Contact:
Midwives Alliance of North America
Geradine Simkins, President & Interim Executive Director
president@mana.org
info@mana.org
231.228.5857 (O)
231.590.3742 (C)

New ACOG Guidelines: Vaginal Birth After Cesarean is a Safe Option

Washington, DC – The Midwives Alliance of North America (MANA), a professional midwifery organization since 1982, commends the American College of Obstetricians and Gynecologists (ACOG) for their updated practice guidelines on Vaginal Birth After Cesarean (VBAC) released July 21, 2010. ACOG’s recent guidelines are less restrictive than previous ones. The new guidelines state that VBAC is a “safe and appropriate choice” for most women who have had a prior cesarean delivery, including some women who have had two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar.

There has been a dramatic increase in cesarean delivery in the United States (from 5% in 1970 to nearly 32% in 2009) and a rapid decrease of VBACs (from 28% in 1996 followed by a decline to 8% in 2006). Lack of VBAC availability in U.S. hospitals due to practitioner and institutional restrictions, which diminished women’s choices in childbirth, is often cited as the reason for the conspicuous decrease in VBACs. In light of the VBAC restrictions that have become commonplace in most U.S. hospitals, it is noteworthy that ACOG’s new guidelines emphasize a woman’s right to self-determination. The new ACOG guidelines state that even if a hospital does not offer a trial of labor after cesarean (TOLAC), a woman cannot be forced to have a cesarean nor can she be denied care if she refuses a repeat cesarean. In addition, previous ACOG guidelines on VBAC stated that anesthesia and surgery must be “immediately available” for an institution to offer VBAC; the new guidelines have relaxed this restriction.

ACOG has seriously considered recommendations from the National Institutes of Health (NIH) Consensus Development Meeting on vaginal birth after cesarean held in Washington DC in March 2010. Based on the scientific evidence, the NIH expert panel affirmed that risks in VBACs are low, similar to risks of other laboring women, and repeat cesareans expose mothers and infants to serious problems both in the short and long terms. The NIH expert panel concluded that in the absence of a compelling medical reason, most women should be offered a trial of labor after cesarean. The NIH expert panel further recommended that all women be given unbiased educational information during their pregnancies with which to make decisions regarding VBAC in partnership with their healthcare providers. Women should also be offered full informed consent and refusal during their labors.

“While we are pleased that ACOG has issued less restrictive VBAC guidelines and affirmed a woman’s autonomy in her childbirth experience, it is still up to women to take charge of their lives, educate themselves about childbirth practices, and put pressure on their healthcare practitioners to provide the safest birth options for their babies and themselves,” says Geradine Simkins, President and Interim Executive Director of the Midwives Alliance. The Midwives Alliance takes the position that the best interests of most mothers and infants are served when women are given the opportunity to birth under their own power and in their own way with the intention of avoiding primary cesarean deliveries and other unnecessary interventions. An impressive body of research literature shows that the midwifery model of care results in less intervention in the birth process and safe and satisfying outcomes for mothers and babies. In addition, evidence shows that birth in a woman’s home with a trained midwife, or in a freestanding birth center, results in decreased cesarean sections and other obstetrical interventions. “We want women to have all the choices they need to have healthy pregnancies and give birth safely,” say Simkins, “and we are pleased that ACOG’s new guidelines on VBAC will add another choice to the menu of maternity care options.”

For more information on the Midwives Alliance visit http://mana.org/. For information on practitioner and childbirth options visit Mothers Naturally atwww.mothersnaturally.org.

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STATE OF FLORIDA CELEBRATES LICENSED MIDWIVES WEEK OCTOBER 5 – 9

STATE OF FLORIDA CELEBRATES
LICENSED MIDWIVES WEEK OCTOBER 5 – 9

Governor Charlie Crist Signs Proclamation Heralding Midwives for Dedicated Care

SARASOTA, FL (October 5, 2009) – Governor Charlie Crist signed a proclamation today observing October 5 through the 9 as Licensed Midwives Week in the State of Florida, upholding midwives for being “dedicated to the care of pregnancy and childbirth and treat[ing] each woman’s pregnancy according to her unique physical and personal needs.”  Governor Crist’s proclamation also recognized midwives for their role in the need to “improve birth outcomes in the State of Florida and ensure that women are given proper care and treatment in all phases of childbirth.”

In honor of this week, Florida Friends of Midwives (FFOM), a non-profit grassroots organization dedicated to promoting and supporting the practice of midwifery in Florida, will be hosting various community events throughout the state this month to celebrate the more than 110 Licensed Midwives in the Sunshine State.

Florida Licensed Midwives Week coincides with National Midwifery Week, a time to recognize the contributions of Certified Nurse Midwives (CNMs), Certified Midwives (CMs) and Certified Professional Midwives (CPMs) nationwide.  The American College of Nurse Midwives (ACNM) publicly announced the week with an introduction to midwifery.  “The heart of midwifery care for women and newborns lies more in the nature of that care than in its specific components. Midwifery practice has a firm foundation in the critical thought process and is focused on the prevention of disease and the promotion of health, taking the best from the disciplines of midwifery, nursing, public health and medicine to provide safe, holistic care.”

Midwives have a long and valued history in Florida. The state first passed legislation to license direct-entry midwives in 1931. In the 77 years since, Florida’s licensed midwives have continued to tirelessly serve the families of Florida and to ensure the continued availability of safe, evidence-based birthing options for Florida’s families.  In 1992, Governor Lawton Chiles declared the first-ever Licensed Midwives Week. More women than ever before are seeking out licensed midwives for maternity care. According to the latest data from the Florida Council of Licensed Midwifery, births managed by Licensed Midwives in the state grew by about 5.5% from 2005 to 2006.

“We are honored every day to serve Florida’s mothers, babies, and families,” says Sarasota Licensed Midwife Alina Vogelhut, LM. “It means so much for our profession to be honored by Governor Charlie Crist and the State of Florida.”

Midwifery in Florida

In Florida, two types of midwives are allowed to practice:  Certified Nurse-Midwives and Licensed Midwives (a Florida state licensure), also known as direct-entry midwives.  Throughout the state, about 11.2 percent of births are estimated to be managed by midwives, rather than by OB-GYNs. Many birth centers and midwives have reported a significant increase in business in the past year. This increase is believed to be a result of various factors, primarily a greater number of women seeking alternative birthing choices due to an unhealthy increase in caesarean sections and other unnecessary interventions that frequently occur in hospital settings.  In a 2006 report on Florida Licensed Midwives, midwives had a caesarean section rate of 6.3 percent compared to a 36.64 percent statewide average in hospitals the same year.

For more information of midwifery in Florida, please visit www.flmidwifery.org.

About Florida Friends of Midwives

Florida Friends of Midwives is a non-profit grassroots organization dedicated to promoting the Midwives Model of Care and supporting the practice of midwifery in Florida. Florida Friends of Midwives was formed to support midwives who offer safe, cost-effective, evidence based care to Florida’s families.  For more information, please visit www.flmidwifery.org.

MEDIA CONTACT:

Laura Gilkey

(941)915-8115

info@flmidwifery.org

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Reducing Infant Mortality

Reducing Infant MortalityOn Wednesday evening at at 11:00 PM Reducing Infant Mortality, Improving the Health of Babies went LIVE!!!

The video can be seen and downloaded at the website:
www.reducinginfantmortality.com

This is a free film. Please use it, show it, put it on your website, link to it, and most of all, send the link to policy makers. Send it to your State and National Senators and Representatives. Until the end of August, your representatives and senators are in their home offices. This is the perfect time to make an appointment to see your legislator and talk to them personally. Can you imagine if 10 people from your district insist on having an appointment to talk about maternal/infant health care20in the next 2 weeks? What if we continue on,. making appointments and showing up to talk to their aides after they return to Washington? What if they each have many copies of Reducing Infant Mortlaity on their desks, and showers of emails with letters about the rights and needs of infants and women and links to the film? I can imagine this. Can you? This is one way we can make a material difference.

Send it to your local Health Department. Send it to your local Hospital. Send it to your State  Department of Health! (In Georgia, they requested a copy!) Link to it on Facebook and My Space! Post it on your favorite networking sites. It is open source which means you can use it any way you like as long as you don’t change it or delete the credits. We are counting on you to use this film to help your voice to be heard.

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The Lie of the EDD: Why Your Due Date Isn’t when You Think

The Lie of the EDD: Why Your Due Date Isn’t when You Think

September 24, 2008 by Misha Safranski

We have it ingrained in our heads throughout our entire adult lives-pregnancy is 40 weeks. The “due date” we are given at that first prenatal visit is based upon that 40 weeks, and we look forward to it with great anticipation. When we are still pregnant after that magical date, we call ourselves “overdue” and the days seem to drag on like years. The problem with this belief about the 40 week EDD is that it is not based in fact. It is one of many pregnancy and childbirth myths which has wormed its way into the standard of practice over the years-something that is still believed because “that’s the way it’s always been done”.

The folly of Naegele’s Rule

The 40 week due date is based upon Naegele’s Rule. This theory was originated by Harmanni Boerhaave, a botanist who in 1744 came up with a method of calculating the EDD based upon evidence in the Bible that human gestation lasts approximately 10 lunar months. The formula was publicized around 1812 by German obstetrician Franz Naegele and since has become the accepted norm for calculating the due date. There is one glaring flaw in Naegele’s rule. Strictly speaking, a lunar (or synodic – from new moon to new moon) month is actually 29.53 days, which makes 10 lunar months roughly 295 days, a full 15 days longer than the 280 days gestation we’ve been lead to believe is average. In fact, if left alone, 50-80% of mothers will gestate beyond 40 weeks.

Variants in cycle length

Aside from the gross miscalculation of the lunar due date, there is another common problem associated with formulating a woman’s EDD: most methods of calculating gestational length are based upon a 28 day cycle. Not all women have a 28 day cycle; some are longer, some are shorter, and even those with a 28 day cycle do not always ovulate right on day 14. If a woman has a cycle which is significantly longer than 28 days and the baby is forced out too soon because her due date is calculated according to her LMP (last menstrual period), this can result in a premature baby with potential health problems at birth. 

The inaccuracy of ultrasound

First trimester: 7 days

14 – 20 weeks: 10 days

21 – 30 weeks: 14 days

31 – 42 weeks: 21 days

Calculating an accurate EDD

Recent research offers a more accurate method of approximating gestational length. In 1990 Mittendorf et Al. undertook a study to calculate the average length of uncomplicated human pregnancy. They found that for first time mothers (nulliparas) pregnancy lasted an average of 288 days (41 weeks 1 day). For multiparas, mothers who had previously given birth, the average gestational length was 283 days or 40 weeks 3 days. To easily calculate this EDD formula, a nullipara would take the LMP, subtract 3 months, then add 15 days. Multiparas start with LMP, subtract 3 months and add 10 days. The best way to determine an accurate due date, no matter which method you use, is to chart your cycles so that you know what day you ovulate. There are online programs available for this purpose. Complete classes on tracking your cycle are also available through the Couple to Couple League.

ACOG and postdates

One of the most vital pieces of information to know when you are expecting is that ACOG itself (American College of Obstetricians and Gynecologists) does not recommend interfering with a normal pregnancy before 42 completed weeks. This is why knowing your true conception date and EDD is very important; if you come under pressure from a care provider to deliver at a certain point, you can be armed with ACOG’s official recommendations as well as your own exact due date. This can help you and your baby avoid much unnecessary trauma throughout the labor and delivery. Remember, babies can’t read calendars; they come on their own time and almost always without complication when left alone to be born when they are truly ready.

Sources:

Mittendorf, R. et al., “The length of uncomplicated human gestation,” OB/GYN, Vol. 75, No., 6 June, 1990, pp. 907-932.

ACOG Practice Bulletin #55: Clinical Management of Post-term Pregnancy

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Current Resources for Evidence-Based Practice

Four times each year, Childbirth Connection contributes “Current Resources for Evidence-Based Practice” to both Journal of Obstetric, Gynecologic and Neonatal Nursing and Journal of Midwifery and Women’s Health. The March/April column includes discussion of the new perinatal standards endorsed by the National Quality Forum (read more about the measures below).

Download JOGNN March/April (free PDF)
Download JMWH March/April (free PDF)
Click here for all Evidence Columns 2003-2009

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CDC releases birth stats for 2007

CDC releases birth stats for 2007

Yesterday the CDC released the Preliminary Data for births in 2007.  The birth rate is up, and so is the cesarean section rate, now nearly 32% of all births: “The cesarean delivery rate rose 2 percent in 2007, to 31.8 percent, marking the 11th consecutive year of increase and another record high for the United States.”

The CDC’s press release is included below. And you can find the entire report at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf

 

For Immediate Release: March 18, 2009
Contact: CDC National Center for Health Statistics
Office of Communication, (301) 458-4800

Teen Birth Rates Up Slightly in 2007 for Second Consecutive Year

The birth rate for U.S. teens aged 15 to 19 increased by about 1 percent in 2007, from 41.9 births per 1,000 in 2006 to 42.5 in 2007, according to a report Printable PDF released today by the Centers for Disease Control and Prevention. This is the second year in a row that teen births have gone up. They increased 3 percent in 2006 following a 14-year decline.

Birth rates also increased for women in their 20s, 30s and early 40s, but remained unchanged for younger teens and pre-teens aged 10-14. Only Hispanic teens noted a decline in the birth rate, which fell 2 percent in 2007 to 81.7 births per 1,000.

Unmarried childbearing increased to historic levels in 2007 for women aged 15-44. An estimated 1.7 million babies were born to unmarried women in 2007, accounting for 39.7 percent of all births in the United States  an increase of 4 percent from 2006. Unmarried childbearing has increased 26 percent since 2002 when the recent steep increases began.

The report, “Births: Preliminary Data for 2007,” Printable PDF from CDC’s National Center for Health Statistics [ http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf ]  is based on an analysis of nearly 99 percent of birth records reported by 50 states, the District of Columbia, and U.S. territories as part of the National Vital Statistics System.

Other findings:

    * Total U.S. births rose in 2007 to over 4, 317,119, the highest number of births ever registered in the United States.
    * The cesarean delivery rate rose 2 percent in 2007, to 31.8 percent, marking the 11th consecutive year of increase and another record high for the United States.
    * The percentage of low birthweight babies declined slightly between 2006 and 2007, from 8.3 percent to 8.2 percent. This is the first decline in the percentage of low birthweight babies since 1984.
    * The preterm birth rate (infants delivered at less than 37 weeks of pregnancy) decreased 1 percent in 2007 to 12.7 percent. The decline was seen mostly among infants born late preterm (between 34 and 36 weeks).

The full report and a separate report with state births data are available at www.cdc.gov/nchs.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

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Evidence-Based Maternity Care

Consumer Reports has published an excellent article based on the report “Evidence Based Maternity Care: What It Is and What It Can Do” published last fall by Childbirth Connection, the Reforming States Group and Milbank Memorial Fund.  The article summarizes the main points made in the much longer report.

The Consumer Reports article can be read at:

http://www.consumerreports.org/health/medical-conditions-treatments/pregnancy-childbirth/maternity-care/overview/maternity-care.htm


and includes a quiz (http://www.consumerreports.org/health/medical-conditions-treatments/pregnancy-childbirth/maternity-care/maternity-care-quiz/maternity-care-quiz.htm).  The first question is (answer true or false): An obstetrician will deliver better maternity care, overall, than a midwife or family doctor.  Each question includes an explanation of the correct answer.

To learn more about the Millbank Report, see February’s Charis e-newsletter.

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When Should a Child Attend a Sibling’s Birth?

When Should a Child Attend a Sibling’s Birth?
By Penny Simkin, P.T. 

Penny has had the pleasure of teaching sibling preparation classes for children since 1978. Many of these children were present at their siblings’ births. She has also attended numerous births where older siblings were present. In every case the children were a positive addition, and by being themselves, contributed to the atmosphere of normalcy and family closeness. However, there are situations when a child probably should not attend a birth. To help parents decide, Penny prepared the following list of prerequisites for a positive birth experience for a child who is in attendance. If they cannot be met, perhaps the child would be better off not attending the birth.

1. Preparation of the parents. They need to feel comfortable about birth and know how to relax.

2. A desire by parents and child (if old enough to make such a decision) for the child to be there. If the child is hesitant or reluctant to attend the birth, parents should respect that.

3. An assessment by the parents of their child’s emotional readiness. A child who is ill and feels badly may not tolerate the birth experience well.

4. Preparation for the birth. There are books, videos and teaching aids to help prepare them. Family discussions are wonderful.

5. A support person for the child, and not the Father. He is Mom’s support. Maybe a relative or close friend to look after the child’s needs and help with interpretations and explanations as needed.

6. A labor and delivery staff in a hospital setting (midwives, nurses, doctors) for whom it won’t be upsetting to have a child present. Check on this well in advance.

7. An alternate plan to use if the child is sick, asleep (and will not wake for the birth), bored, changes her mind, or if labor complications develop that either require a change of environment or is too intense for the child or parents to handle with the child there. Talking about this with the child prior to birth is part of sensitive preparation.

8. Realistic expectations of the child. One should not expect a 2-year-old or 4-year-old to be transformed during labor. They still fuss, need to go to the bathroom, need cuddling and want to know where their Legos are. This is where the support person is a blessing!

There is no single correct answer to whether or not children should be present at the birth of a sibling. Parents should examine their motivations, their child’s readiness and desire to participate, and the circumstances at the time.

Note from Susan Oshel, CPM (Charis Director of Midwifery Studies):
This article was reprinted from Midwifery Today, Winter 1993 No. 28.
Penny gave permission to copy and use it in classes.  
Being close to families I’ve personally helped, discussing and sharing these considerations, has helped initiate wonderful experiences with children during births. 

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C-Sections Prior to 39 Weeks Gestation Pose Significantly Greater Risk

Elective Cesarean Sections 

 The New England Journal of Medicine just published a study which found “significantly increased risks” for babies when elective (no medical reason) cesareans are performed before 39 weeks of gestation, accounting for more than one third of all cesarean sections. 

 “In this large, multi-center study in the United States, more than one third of elective repeat cesarean deliveries at term were performed before 39 weeks of gestation. As compared with deliveries at 39 weeks, these early deliveries were associated with a significantly increased risk of composite outcomes that included neonatal death,  as well as  individual neonatal adverse outcomes that included respiratory complications and admission to the neonatal ICU.” ~NEJM abstract

There are alarming implications due to the rise in elective cesareans prior to 39 weeks in the US accompanied by vast surprise that OBs have not followed ACOG’s own recommendation to wait until 39 weeks for elective cesareans.  Following is an expert editorial on the impact and implications of this study by Michael F. Green, M.D.  Is it a small risk?  Read his editorial and the full abstract.  Nothing small about the numbers of babies ending up in NICU’s across the country.

~Susan Oshel, director of midwifery studies, Charis Childbirth
(this article can be found in the Charis e-newsletter, 01/2009  – Subscribe Free)
(c) 2009 Charis Childbirth, all rights reserved, used by permission

Visit The New England Journal of Medicine January 08, 2009 full abstract:
January 8, 2009 NEJM
– Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes –
(Adobe Acrobat Required)

The NEW ENGLAND JOURNAL of MEDICINE
E D I T O R I A L

 Making Small Risks Even Smaller
Michael F. Greene, M.D. 

Cesarean sections performed without antecedent labor are associated with a higher risk of respiratory distress than those performed after the onset of labor, despite the fact that they may have been done at full term (at least 37 weeks of gestation). This respiratory distress is usually transient tachypnea of the newborn, which is generally milder in both severity and duration than respiratory distress syndrome due to hyaline membrane disease in premature babies. Unlike hyaline membrane disease, which results from a surfactant deficiency, transient tachypnea of the newborn results from delayed clearance of fetal alveolar fluid. The volume of fetal alveolar fluid decreases progressively but not linearly with advancing gestational age. In fetal guinea pigs, oxytocininduced labor induces elevated levels of catecholamines, which stimulate β-adrenergic sodium channels that clear fluid from fetal lung alveoli to permit gas exchange in the neonate.2

In this issue of the Journal, Tita et al.3 report the results of an observational study of 13,258 women with viable singleton pregnancies who underwent elective repeat cesarean section at term (37 weeks or greater) at 19 academic medical centers in the United States. The primary outcome was a composite measure of neonatal mortality and morbidity, which included respiratory distress syndrome, transient tachypnea of the newborn, hypoglycemia, newborn sepsis (suspected and proved), seizures, necrotizing enterocolitis, hypoxic-ischemic encephalopathy, cardiopulmonary resuscitation or ventilator support within 24 hours after birth, cord-blood arterial pH below 7.0, a 5-minute Apgar score of 3 or below, admission to the neonatal intensive care unit (ICU), and prolonged hospitalization (5 days or longer).

Tita et al. found that 35.8% of the elective repeat cesarean deliveries were performed at less than 39 completed weeks of gestation, despite best-obstetrical-practice recommendations to deliver after 39 weeks.4 No babies had necrotizing enterocolitis or hypoxic-ischemic encephalopathy, and only one baby died (after delivery at 39 weeks of gestation). However, the risk of neonatal complications increased with decreasing gestational age before 39 weeks and was increased even among babies delivered in the last 3 to 4 days of the 38th week of gestation. The higher risk of composite neonatal complications in babies delivered before 39 weeks of gestation was driven by adverse respiratory outcomes, hypoglycemia, suspected sepsis, and medical interventions (admission to the ICU, mechanical ventilation, and prolonged hospitalization) in response to these clinical conditions. There was no increase in proved sepsis at earlier gestational ages.

 Since signs that lead pediatricians to suspect newborn sepsis include tachypnea, grunting, flaring of the nasal alae, intercostal retractions, decreased breath sounds, and apnea, it could reasonably be said that the composite outcome measure largely reflects clinical respiratory distress and hypoglycemia. The incidence of the primary outcome declined after 39 weeks of gestation but rose again after 41 weeks, leaving a relatively narrow 2-week window of minimal risk in which elective repeat cesarean deliveries could optimally be performed.

The differences between the women who delivered before 39 weeks of gestation and those who delivered at or after 39 weeks are revealing. The women who delivered earlier were more likely to be married, to be white, to have had a first or second-trimester ultrasound examination, and to be privately insured. In short, a woman in this group was more likely to be a private patient and to place a premium on her own doctor’s performing the delivery. The physicians probably reciprocated, wanting to deliver their own patients to foster the doctor-patient relationship and improve patient satisfaction. To accommodate busy schedules and to minimize the chance that a patient will begin labor and require a non-elective procedure when her doctor might not be available, procedures are frequently scheduled just before 39 weeks of gestation.

As desirable as it is to minimize neonatal complications, it is imperative to avoid perinatal death. This study was not a treatment trial to assess overall perinatal death resulting from alternative strategies of elective delivery at term. Such a trial would include an accounting of fetal deaths among women waiting to deliver at later gestational ages. Enrollment in the current observational study required a living fetus and did not include any fetal deaths. Among the 4743 viable babies delivered at less than 39 weeks of gestation in the current study, there were no neonatal deaths and there was no assessment of potential long term complications. As the investigators correctly note, all the complications observed after delivery at 37 to 39 weeks of gestation must be weighed against the risk of fetal death while awaiting completion of the 38th week of gestation. That risk has been estimated at 1 in 10005,6 and could be greater than the risk of neonatal death associated with delivery during this 2-week gestational period. Antenatal surveillance of fetal well-being to prevent fetal death is unlikely to reduce the risk of fetal death below 0.8 in 1000.7

Some have suggested that amniocentesis should be performed to determine fetal lung maturity before elective delivery earlier than 39 weeks of gestation. In two small case series of women undergoing amniocentesis in the third trimester, several patients required emergency deliveries, but there were no perinatal deaths.8,9 The combined size of the two series (1475 patients), however, does not rule out a procedure-related risk of perinatal death that is potentially greater than the risk of neonatal death among babies delivered at less than 39 weeks. Tita et al. point out that they had no information regarding the results of amniocenteses to determine fetal lung maturity that may have been performed for women in their study. Therefore, it is unknown whether testing for fetal lung maturity may have reduced the incidence of complications or death in the babies delivered at 37 to 39 weeks of gestation and whether some complications occurred despite reassuring results of testing.

Given the small risk of perinatal death at term (probably less than 1 in 1000), a randomized trial to demonstrate the elective delivery strategy resulting in the least risk of perinatal death and long-term complications would have daunting power and sample-size challenges. Even if the optimal strategy could be defined, its implementation might require overcoming the dread of late stillbirth and convincing patients (and their doctors) that having “their doctor” perform the delivery is less important than avoiding the complications associated with early term birth.

No potential conflict of interest relevant to this article was reported.

From the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston.

1. van den Berg A, van Elburg RM, van Geijn HP, Fetter WPF. Neonatal respiratory morbidity following elective caesarean section in term infants: a 5-year retrospective study and a review of the literature. Eur J Obstet Gynecol Reprod Biol 2001;98:9-13.

2. Norlin A, Folkesson HG. Alveolar fluid clearance in late-gestational guinea pigs after labor induction: mechanisms and regulation. Am J Physiol Lung Cell Mol Physiol 2001;280:L606-L616.

3. Tita ATN, Landon MB, Spong CY, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009;360:111-20.

4. ACOG Practice Bulletin No. 97: fetal lung maturity. Obstet Gynecol 2008;112:717-26.

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

6. Smith CG, Pell JP, Dobbie R. Cesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003;362: 1779-84.

7. Dayal AK, Manning FA, Berck DJ, et al. Fetal death after normal biophysical profile score: an eighteen-year experience. Am J Obstet Gynecol 1999;181:1231-6.

8. Stark CM, Smith RS, Lagrandeur RM, Batton DG, Lorenz RP. Need for urgent delivery after third-trimester amniocentesis. Obstet Gynecol 2000;95:48-50.

9. Gordon MC, Narula K, O’Shaughnessy R, Barth WH Jr. Com-plications of third-trimester amniocentesis using continuous ultrasound guidance. Obstet Gynecol 2002;99:255-9.

Copyright © 2009 Massachusetts Medical Society.
n engl j med 360;2 nejm.org january 8, 2009
Downloaded from http://www.nejm.org at VA LIBRARY NETWORK on January 8, 2009

Scriptures and Prayers for Pregnancy and Birth

Strength for Childbearing
Lily Bateman & Kristin Schuchmann
(all scriptures quoted are from the New International Version of the Bible)

Exodus 1:19
“The midwives answered Pharaoh, ‘Hebrew women (God-fearing women) are not like Egyptian women, they are vigorous and give birth before the midwives arrive.’”

Lord, thank you that I have vigor and strength to deliver this child you have given us!

Exodus 15:2
“The Lord is my strength and my song.  He had become my salvation.”

Lord, You are my song in the light and in the dark.  I will always sing to you, my Savior and my strength.

2 Samuel 22:33
“It is God who arms me with strength and makes my way perfect.”

Lord, You make the way of our baby’s delivery perfect.  You cause my body to be strong and work perfectly in order to glorify yourself in the delivery of our child.

Psalm 18:6
“In my distress I called to the Lord, I cried to God for help.  From his temple he heard my voice; my cry came before him, into his ears.”

Lord, I call to you for any help I will ever need, no matter what my situation.  I call on You first… and you hear my call.

Psalm 46:1-2
“God is our refuge and strength, an ever-present help in trouble.  Therefore we will not fear…”

Lord, You are the only ever-present one.  Thank you for being with us during labor and delivery.  I will not fear.

Psalm 139:14
“I praise you because I am fearfully and wonderfully made…”

Lord, You made me.  You created me to carry and deliver children.  Thank you for making me in such a wonderful fashion.

Isaiah 26:3
“You will keep in perfect peace him whose mind is steadfast, because he trusts in you.”

Lord, You are my supernatural, perfect peace.  I know your peace and will know it during labor and delivery of this child.  My focus is on You and your goodness.

Isaiah 40:30-31
“Even youths grow tired and weary, and young men stumble and fall, but those who hope in the Lord will renew their strength.”

Lord, You will renew my strength during delivery.  My strength will not wear out because it is from You and my hope is in You.

Isaiah 41:10
“So do not fear, for I am with you.  Do not be dismayed for I am your God.  I will strengthen you and help you.  I will uphold you with My righteous right hand.”

Because You, Lord, are staying with me throughout my labor and delivery, I have no reason to fear.

Isaiah 43:2
“When you pass through the waters, I will be with you…”

Lord, thank you for not leaving us alone.  Thank you for being with our baby as it passes through the waters in my womb.

Isaiah 51:12
“I, even I, am He who comforts you.”

Thank you, Holy Spirit, for always being my comfort.  You always bring the comfort I need.

Philippians 4:13
“I can do everything through him who gives me strength.”

Lord, I confess I can do this through You.  It is You who gives me strength.

Psalm 119:165
“Great peace have they who love your law, and nothing can make them stumble.”

Proverbs 14:30
“A heart at peace gives life to the body.”

Isaiah 54:13
“…and great will be your children’s peace (shalom).”

Thank you, Lord for your promise of peace.  I receive the peace that is mine in you, Jesus.  Thank you that my baby’s shalom, peace and total well-being, is secure because of your faithfulness to your servants and to your Word.  May your peace rule and reign and give life during my labor and the delivery of this child you have given us.

(C) Copyright Charis Childbirth, Inc.  All rights reserved.  Used with permission.

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