ICAN Statement about NEJM study        ICAN Report "VBAC Study Comes Under Fire From Physicians"

CIMS statement about NEJM Study        American College of Midwives Statement about NEJM Study

Is Vaginal Birth Risky after Cesarean? -- a reply by medical research Henci Goer to the NEJM Study 

Excerpts from Cited sutdies          Links to additional material and background information / Medical Policies

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Citations & Bilbiography for +Open Letter to Media / VBAC Study

1. ONCE A CESAREAN, ALWAYS A CONTROVERSY – VBAC; Dr. Bruce Flamm. MD,  Obstetrics and Gynecology

2. Obstetrics: Normal and Problem Pregnancies, Gabbe, 1991 edition

p. 668 “A recent summary of 6,258 women who attempted VBAC indicated that 5,356 (86%) were successful with no maternal mortality, thus comparing favorably with an expected mortality of at least 1 death per 1,000 cesarean sections.  … Furthermore, the fetal risk is no higher than that of patients delivering by elective repeat cesarean section, ranging from 2 to 3 percent.”

3. Journal of Allergy & Clinical Immunology 107[4[:732-33, 2001

4. The Relative Risk of Cesarean section (intrapartum and elective) and vaginal delivery; Lilford RJ et al; Br J Obstet Gyneaecol1990:97:883-892

5. Prophylactic Cesarean Section at Term?  New England Journal of Medicine, May 1985, by George B. Feldman, MD, Jennie A. Feldman, MD

6. Diagnosis and Management of Placenta Percreta: A Review, Lynda Hundon et el; Obstetrical and Gynecology Survey Vol 53, No 8, p 48,  CME Review Article 24 1998

7. Effective Care In Pregnancy and Childbirth,  Murray Enkin, MD, FRCS(C), L L D, Marc J. N. C Keirse, MD, DPhil, DPH, FRA NWOG, FRCOG   James Neilson, BSc, MD, FRCOG, Caroline Crowther, MD, DCH, DDU, FRCOG, FRANWOG, Lelia Duley, MD, MSc(Epid), MRCOG, Ellen Hodnett, RN, PhD, and G. Justus Hofmneyr, MBBCH, MRCOG

8. Forty weeks and beyond: pregnancy outcomes by week of gestation. Alexander JM, McIntire DD, Leveno KJ.  Department of Obstetrics and Gynecology, The University of Texas  Southwestern Medical Center at Dallas, Dallas, Texas 75235-9032, USA. jalexa@mednet.swmed.edu Conclusion: “Routine labor induction at 41 weeks likely  increases labor complications and operative delivery without significantly  improving neonatal outcomes.”  

9. Induction of labor as compared with serial antenatal monitoring in post-term pregnancies Hannah, M.E. et al The Canadian Multicenter  Post-term Pregnancy Group, 1992, NEJM, 326 (24), 1587-92

10. Pitocin Insert, Parke-Davis 1996 Warner-Lambert Co.

11. Uterine rupture during a trial of labor after a one- versus two-layer closure of a low transverse cesarean. Emmanuel Bujold, Camille Bujold, Robert J. Gauthier; Ste-Justine Hospital, University of Montreal, Obstetrics and Gynecology, Montreal, Quebec. Abstracts of the 2001 21st Annual Meeting of the Society for Maternal-Fetal Medicine. American Journal of Obstetrics and Gynecology (supplement) 184(1):S18, 2001.

12. Interdelivery Time Affesct Uterine Rupture Risk During trial of Labor after Prior Cesarean, Obstet Gynecol 2001;97:175-177) Dr. Thomas D Ship, Massachuetts General Hospital)

13. Maternal Mortality Rate Grossly Underestimated; Michigan Maternal Mortality Study, Dr.James Gell, ObGyn News 1/13/2000 p. 7  “If the Michigan system underestimates MM to such an estent, then it is likely that other states do as well”

14. Maternal deaths in an urban perinatal network, 1992-1998. Am J Obstet Gynecol 2000 Nov;183(5):1207-12 Panting-Kemp A, Geller SE, Nguyen T, Simonson L, Nuwayhid B, Castro L. Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Illinois at Chicago, 60612, USA.

“The adjusted pregnancy-related maternal mortality ratio was 22.8 maternal deaths per 100,000 live births, with 37% of those deaths (11/30) deemed potentially preventable and a provider factor cited in >80% of these.  

CONCLUSION: Local maternal mortality ratios identified through a peer-review process indicate that the magnitude of the problem is much greater than is recognized through national death certificate data. The high proportion of potentially preventable maternal deaths indicates the need for improvement in both patient and provider education if we are to reduce the maternal mortality ratio to 3.3 maternal deaths per 100,000 live births, the stated national health goal of Healthy People 2000.

15. American College of Obstetricians & Gynecologists “Practice Bulliten #2” on VBAC ~ Oct 1998

16. Optimal Goals for Anesthesia Care in Obstetrics --  joint statement from the American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists (ACOG)  2001

17. Transcript of Good Morning America, 6/20/2000 interview of ACOG president Dr Benson Harer, promoting the idea of “Cesarean on demand as a “woman’s choice” issue  http://www.collegeofmidwives.org/news01/gma%20transcript00a.htm

18. ReJuveness by RichMark International Corp – The Leader in Scar Management / www.rejuveness.com

19. Midwives Deliver Healthy Babies With Fewer Interventions Dr. Roger Rosenblatt, MD University of Washington, Department of  Family Medicine April 18, 1997 NY Times report by TAMAR LEWIN  Original paper “Interspeciality difference in the obstetrical care of low-risk women”, Am J Public Health, 87, 344-351  1997 

20.Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study Aust N Z J Psychiatry 1997 Oct;31(5):728-38 

21.Study of oxytocin use in Austin-area Hospitals, Robbie Davis Floyd, PhD Mothering Magazine, Jan 2001

22. Predictors, prodromes and incidence of postpartum depression. Chaudron LH, J Psychosom Obstet Gynaecol 2001 Jun;22(2):103-12

23. Do not minimize signs of postpartum depression! Early intervention essential to prevent negative consequences for the child. [Article in Swedish] Wickberg B, Hwang P. Psykologiska institutionen, Goteborgs universitet. birgitta.wickberg@psy.gu.se  Lakartidningen 2001 Mar 28;98(13):1534-8

24. “The Safety of Alternative Methods of Childbirth” Peter Schlinzka, PhD, Stanford University, 1999 

25. “Rights of Childbearing Women” -- published by the Maternity Center Association, an 80 year old, non-profit organization  dedicated to improving maternity care ~ 212 / 777-5000

26. The Thinking Woman Guide to a Better Birth, 1998, Obstetrical Myth Versus Reseach Realities, 1995 Henci Goer; Bergin & Garvey Westport, CT

27. Midwifery Care: The "Gold Standard" for Normal Childbirth? Albers, et al; Birth 26:1 March 1999

28. “Pursuing the Birth Machine” Marsden Wagner, MD, 1994, ACE Graphics, Australia Ph +61 2 516-3077

29. "Your Guide to Safe and Effective Care During Labor and Birth", Recommendations by Maternity Center Association, 1998, NYC, 212 / 777-5000

30. “VBAC – Don’t get by the swinging door”, Dr. Steven Clark, Director of Women and Newborn Services, University of Utah Health Services, paper presented at the Phillip DiSia Medical Society, May 4, 2001 – criticism of single layer closure as directly increasing the rate of uterine rupture.

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Excerpts from Studies Cited

Journal of Obstetric, Gynecology and Neonatal Nursing, editorial, "Is it Time to Change the Paradigm" Suzan Kardong-Edgren, RNC, MS Sept-Oct 1999

Narcotic drugs and anesthetics given to mothers during labor & delivery associated with illegal drug use by offspring as an adolescents or adult

The introduction in the 1940s of heavy analgesia and sedation during labor and birth may have contributed significantly to the illegal drug use that exploded in American in the 1960s and continues today (Jacobson, et al, 1990, Jacobson, Nyberg, Eklund, Bygdeman & Rydberg, 1988) ...80% of US women receive epidurals ... narcotics are added to epidural analgesia to speed and enhance pain relief. These drugs cross the placenta to the fetus (Thorpe & Breedlove, 1996)

Synopsis: These researchers found that when mothers received opiates [i.e. narcotics], barbiturates or nitrous oxide gas for longer than one hour and within 10 hours of the birth, their offspring were significantly more likely to become addicted to opiates [narcotics] if they experimented with or took drugs later in life. The risk of substance abuse increased as the number of pain medication doses in labor increased and they recommended that narcotic pain medication which crosses the placenta, not be used in labor. Journal of Obstetric, Gynecology and Neonatal Nursing, editorial, "Is it Time to Change the Paradigm" Suzan Kardong-Edgren, RNC, MS Sept-Oct 1999

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Epidurals increase caesarean section rate http://www.jr2.ox.ac.uk/Bandolier/band34/b34-3.html Bandolier took the data from each study and plotted the Caesarean rate for epidural and non-epidural groups on a L'Abbé plot with the numbers of women included in each study, and calculated odds ratio and NNT. There was a consistent increase in Caesarean section rate in women having epidural analgesia. The overall weighted difference was 10%, generating an NNT of 10 (95%CI 8.4 - 13), with an odds ratio of 2.6 (2.1 - 3.2).  This means that for every 10 women in labour having epidural analgesia, one more will have a Caesarean section, who would not have done had they had another form of analgesia.  Reference: 1.SC Morton, MS Williams, EB Keeler, JC Gambone, KL Kahn. Effect of epidural analgesia for labor on the Cesarean delivery rate. Obstetrics & Gynecology 1994 83: 1045-52.

"The Midwifery Model of Care differs from the obstetrical model in ways that are beneficial to mothers and babies. Midwifery care produces equally good or better maternal and infant outcomes as does obstetrical management, with much lower rates of intervention and medication." ”The Thinking Woman Guide to a Better Birth, Henci Goer, 1999 “

 “One New Jersey CNM practice that cared for 274 women, 240 of whom gave birth at home between 1990 an 1994, showed a savings to clients and/or the insurance industry of $1.25 million.” ”The Thinking Woman Guide to a Better Birth, Henci Goer, 1999 “  

"In the future liability insurance companies may even favor physicians who collaborate with midwives, because litigation is much less likely to occur when outcomes are good and client satisfaction is high." ”The Thinking Woman Guide to a Better Birth, Henci Goer, 1999 “

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“Ample data support the premise that on average, midwives and physicians manage labor and delivery differently in healthy women at term (2-4), with midwives more likely to use low technology care measures [such as} oral fluids, walking and position change, bath or showers,... and bedside emotional support. These care measures are less resource intensive and are appreciated by many women." Midwifery Care: The "Gold Standard" for Normal Childbirth? Albers, et al; Birth 26:1 March 1999

Because all drugs and invasive technologies used in labor have potential averse effects, it seems obvious that using less of them, where possible, is a good idea and should promote the health of childbearing women and their babies. Midwifery Care: The "Gold Standard" for Normal Childbirth? Albers, et al; Birth 26:1 March 1999

The consistent message is that midwifery care for essentially healthy women is at least as safe and effective as physician care. Given the  effectiveness of midwifery care for labor, the style of intrapartum care should be a priority discussion topic in the national health agenda. ... We need to be asking why so many aspects of current [obstetrical] practice are inconsistent with evidence-based recommendations for childbirth. Midwifery Care: The "Gold Standard" for Normal Childbirth? Albers, et al; Birth 26:1 1999

Low-risk women at term are the clear majority of all childbearing women and nearly all give birth in hospitals. As such normal childbirth claims a significant portion of our total health care budget. If using fewer technologic care measures in healthy women is equally effective as using them more routinely and if this style of care is less expensive and more pleasant for the laboring woman, it calls for a radical reorientation of the process and goals of intrapartum care. Midwifery Care: The "Gold Standard" for Normal Childbirth? Albers, et al; Birth 26:1 March 1999   

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Incidence and Detection of Postpartum Depression 
and Difficulties in Maternal Child Relationship 

"Significant adverse psychological effects were associated with the mode of delivery. Those women who had spontaneous vaginal deliveries were most likely to experience a marked improvement in mood and an elevation in self-esteem across the late pregnancy to early postpartum interval. In contrast, women who had Caesarean deliveries were significantly more likely to experience a deterioration in mood and a diminution in self-esteem. The group who experienced instrumental intervention in vaginal deliveries fell midway between the other two groups, reporting neither an improvement nor a deterioration in mood and self-esteem.  CONCLUSIONS: The findings of this study suggest that operative intervention in first childbirth carries significant psychological risks rendering those who experience these procedures vulnerable to a grief reaction or to post-traumatic distress and depression."  Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study Aust N Z J Psychiatry 1997 Oct;31(5):728-38 

" Women with a history of depression during pregnancy should be monitored for signs of postpartum depression for a minimum of 4 months. Obstetricians are in a unique position during the postpartum check-up to screen women for these predictors of future postpartum depression and possibly to avert the development of a clinically significant depressive episode."  Predictors, prodromes and incidence of postpartum depression. Chaudron LH, J Psychosom Obstet Gynaecol 2001 Jun;22(2):103-12

" Recent clinical research reveals that postnatal depression is associated with disturbances in the mother-infant relationship. These disturbances have in turn an adverse impact on the child's cognitive and emotional development. Postnatal depression affects 8-15 percent of women in the first months after delivery." Do not minimize signs of postpartum depression! Early intervention essential to prevent negative consequences for the child. [Article in Swedish] Wickberg B, Hwang P. Psykologiska institutionen, Goteborgs universitet. birgitta.wickberg@psy.gu.se  Lakartidningen 2001 Mar 28;98(13):1534-8

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Internet Links to additional data and background material
VBAC safety and medical policies

Web Site from advertisement “A Scar is Born Every 39 Seconds” Http://www.rejuveness.com

ACOG Practice Bulletin for VBAC -- in Oct of 1998 ACOG re-classified labor subsequent to CS as the highest possible risk category, with mandatory continuous EFM and the re-emergence of scheduled elective Cesareans for mothers who plan to give birth in community hospitals which do no have 24 hours anesthesia and surgical scrub teams

Optimal Goals for Anesthesia Care in Obstetrics ACOG Committee opinion issued May 2001: Joint statement from the American Society of Anesthesiologists (ASA)

Transcript and Rebuttal to Good Morning America's June 20th program on medically unnecessary elective c-sections to avoid the infrequent and non-fatal complications of normal childbirth, with Dr. Marsden Wagner and Dr. Benson Harer, president of the American College of Obstetricians and Gynecologists

ONCE A CESAREAN, ALWAYS A CONTROVERSY – VBAC; Dr. Bruce Flamm. MD,  
Obstetrics and Gynecology

Three peer-reviewed articles on maternal mortality

Abstracts on Single Layer Closure from Peer-reviewed Journals 1976 to 2001 

VBAC Alert - Placenta Previa / Placenta Accreta/Percreta

VBAC Rupture Rate Increased by Short Interval Between Pregnancies

Predicting incomplete uterine rupture with sonography

1 and 2 layer uterine closing after Cesarean surgery & increased complications -- placenta percreta and maternal death -- for VBAC mothers after 1-layer closing - comments by Ina May Gaskin, Certified Professional Midwife 

Peer-reviewed articles on Postpartum Depression, operative delivery and deleterious effect of PPD on the mother child relationship, breastfeeding and childhood developmental problems for the baby

Common Maternity Care practices that are harmful or ineffective and should be eliminated

Iatragenic Dangers of Medicalized Childbirth Practices ~ Autism linked to Pitocin induced labor, Adolescent drugs addition linked to narcotic use in labor, Nosocomial fatalities in US hospitals

Autistic disorders and the intrapartum use of Pitocin to induce or augment labor 

Hospital-related (Nosocomial) Maternity Mortality

Obstetricians and Midwives report personal experience with maternal mortality

Charting a Course for the 21^st  Century ~ the Future of Midwifery 
http://futurehealth.ucsf.edu/pdf_files/midwifry.pdf

The Safety of Alternative Approaches to Childbirth by Dr. Peter Peter Schlenzka, PhD, Stanford University, Mar 1999

Effective Guide to Pregnancy Care Excerpts from Synopsis Cochrane DataBase 
Systemic Review of Evidence-based Maternity Care1

"Expecting Trouble", an expose on the failure of current obstetrician-dominated form of maternity care Author  Dr. Tom Strong, obstetrician (Book Review) 

Links to CS topics on the American College of Nurse Midwives Web site

ACNM Position Statement on VBAC

The Elective Cesarean Section Debate: Consider Your Options

Unnecessary Cesarean Sections: The Nurse-Midwifery Solution

Expansion of Reproductive Freedom to Include Midwifery Model of Care Resolution 
passed by the National Organization for Women, July 1999:

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