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

For Immediate Release
July 27, 2010

Midwives Alliance of North America
Geradine Simkins, President & Interim Executive Director
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 For information on practitioner and childbirth options visit Mothers Naturally

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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:

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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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


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 [ ]  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


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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)


 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 january 8, 2009
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