Delivery after previous caesarean section

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Vaginal birth after caesarean
MeSH D016064

In case of a previous caesarean section a subsequent pregnancy can be planned beforehand to be delivered by either of the following two main methods:

Contents

Both have higher risks than a vaginal birth with no previous caesarean section. There are many issues which affect the decision for planned vaginal or planned abdominal delivery. There is a slightly higher risk for uterine rupture and perinatal death of the child with VBAC than ERCS, but the absolute increased risk of these complications is small, especially with only one previous low transverse caesarean section. [1] A large majority of women planning VBAC will achieve a successful vaginal delivery, although there are more risks to the mother and baby from an unplanned caesarean section than from an ERCS. [2] [3] Successful VBAC also reduces the risk of complications in future pregnancies more than ERCS. [4]

In 2010, the National Institutes of Health, U.S. Department of Health and Human Services, and American Congress of Obstetrics and Gynecology all released statements in support of increasing VBAC access and rates. [5] [6] [4] [7] Recently, it is recognized that as the number of cesarean sections a patient undergoes increases so does the risk of significant obstetrical complications [8] It is still suggested to try VBAC over ERCS even with its slightly higher risk of uterine rupture. Both VBAC and ERCS have risks, it is always better to decide delivery based on birthing person's body condition and preferred birthing experience, and advice from health professionals.

TOLAC (trial of labor after caesarean) is an attempt at vaginal delivery to see whether it can succeed in resulting in a VBAC. If it turns out not to progress acceptably, then a caesarean is performed.

Technique

Where the woman is labouring with a previous section scar (i.e. a planned VBAC in labour), depending on the provider, special precautions may be recommended. These include intravenous access (a cannula into the vein) and continuous fetal monitoring (cardiotocography or CTG monitoring of the fetal heart rate with transducers on the mother's abdomen). Most women in the UK should be counselled to avoid induction of labour if there are no medical reasons for it, as the risks of uterine rupture of the previous scar are increased if the labour is induced. Other intrapartum management options, including analgesia/anesthesia, are identical to those of any labour and vaginal delivery. [9]

For ERCS, the choice of skin incision should be determined by what seems to be most beneficial for the present operation, regardless of the choice of the previous location as seen by its scar, although the vast majority of surgeons will incise through the previous scar to optimise the cosmetic result. Hypertrophic (very thick or unsightly) scars are best excised because it gives a better cosmetic result and is associated with improved wound healing. On the other hand, keloid scars should have their margins left without any incision because of risk of tissue reaction in the subsequent scar. [10]

Selection criteria

The choice of VBAC or ERCS depends on many issues: medical and obstetric indications, maternal choice and availability of provider and birth setting (hospital, birthing center, or home). Some commonly employed criteria include: [3]

Factors favoring VBAC

Factors favoring ERCS

According to ACOG guidelines, the following criteria may reduce the likelihood of VBAC success but should NOT preclude a trial of labour: having two prior caesarean sections, suspected fetal macrosomia at term (fetus greater than 4000-4500 grams in weight), gestation beyond 40 weeks, twin gestation, and previous low vertical or unknown previous incision type, provided a classical uterine incision is not suspected. [4]

Criteria where ERCS should be performed

The presence of any of the following practically always mean that ERCS will be performed – but this decision should always be discussed with a senior obstetrician: [12]

Outcomes in VBAC versus ERCS

VBAC and ERCS differ in outcomes on many end-points.

The American Congress of Obstetricians and Gynecologists (ACOG) states that VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies than ERCS. [4]

Uterine rupture

A caesarean section leaves a scar in the wall of the uterus which is considered weaker than the normal uterine wall. A VBAC carries a risk of uterine rupture of 22–74/10,000. Slightly lower risk of uterine rupture in women undergoing ERCS (i.e. a section before the onset of labour). [1] Mothers with a previous lower uterine segment cesarean are considered the best candidates for VBAC, as that region of the uterus is under less physical stress during labor and delivery. Although there is higher risk of uterine rupture in VBAC than ERCS, both rates happen to be very low. Sometimes no significant difference in uterine rupture rates is found between the groups of VBAC and ERCS. [13] If a uterine rupture does occur, the risk of perinatal death is approximately 6%. [14] Even it happens, most birthing parents and babies will recover completely after uterine rupture. [15]

Risks to the child

A VBAC carries a 2–3/10,000 additional risk of birth-related perinatal death when compared with ERCS. [1] The absolute risk of such birth-related perinatal loss is comparable to the risk for women having their first birth. [1] Planned VBAC carries an 8/10,000 risk of the child developing hypoxic ischaemic encephalopathy, but the long-term outcome of the infant with HIE is unknown and related to many factors. [1]

On the other hand, attempting VBAC reduces the risk that the child will have respiratory problems after birth such as infant respiratory distress syndrome (IRDS), as rates are estimated at 2–3% with planned VBAC and 3–4% with ERCS. [1]

Conversion from planned VBAC to Caesarean

Of the women who have previously had a Caesarean, only about 8% of them will opt for a VBAC. However, of the 8% that opt for a VBAC, between 75%–80% will successfully give birth vaginally, which is comparable to the overall vaginal delivery rate in the United States in 2010. [2] [3] [16]

The chance of having a successful VBAC is decreased by the following factors: [1]

When the first four factors are present, successful VBAC is achieved in only 40% of cases. In contrast, in women with a previous caesarean section who have had a subsequent vaginal birth, the chance of a successful vaginal birth again is estimated at 87–90%. [1]

Risks in future pregnancies

ERCS, as compared to VBAC, further increases the risks of complications in future pregnancies. Complications whose risks significantly increase with increasing number of repeated caesarean sections include: [1]

Other

Aside from uterine rupture risk, the drawbacks of VBAC are usually minor and identical to those of any vaginal delivery, including the risk of perineal tearing. Maternal morbidity, NICU admissions, length of hospital stay, and medical costs are typically reduced following a VBAC rather than a repeat caesarean delivery.[ citation needed ]

A VBAC, compared with ERCS, carries around 1% additional risk of either blood transfusion (mainly because of antepartum hemorrhage), postpartum haemorrhage or endometritis. [1]

Society and culture

While vaginal births after caesarean (VBAC) are not uncommon today, the rate of VBAC has declined to include less than 10% of births after previous caesarean in the USA. [17] [18] Although caesarean deliveries made up only 5% of births overall in the USA until the mid-1970s, it was commonly believed that for women with previous caesarean sections, "Once a Caesarean, always a Caesarean". A consumer-driven movement supporting VBAC changed medical practice and led to soaring rates of VBAC in the 1980s and early 1990s, but rates of VBAC dramatically dropped after the publication of a highly publicized scientific study showing worse outcomes for VBACs as compared to repeat caesarean and the resulting medicolegal changes within obstetrics. [19] In 2010, the National Institutes of Health, U.S. Department of Health and Human Services, and American Congress of Obstetrics and Gynecology all released statements in support of increasing VBAC access and rates. [5] [20] [7]

Although caesarean sections made up only 5% of all deliveries in the early 1970s, [21] among women who did have primary caesarean sections, the century-old opinion held, "Once a caesarean, always a caesarean." Overall, cesarean sections became so commonplace that the caesarean delivery rate climbed to over 31% in 2006. [4] A mother-driven movement supporting VBAC changed standard medical practice, and rates of VBAC rose in the 1980s and early 1990s. However, a major turning point occurred in 1996 when one well publicized study in The New England Journal of Medicine reported that vaginal delivery after previous caesarean section resulted in more maternal complications than a repeat caesarean delivery. [19] The American Congress of Obstetrics and Gynecology subsequently issued guidelines which identified VBAC as a high-risk delivery requiring the availability of an anesthesiologist, an obstetrician, and an operating room on standby. [22] Logistical and legal (professional liability) concerns led many hospitals to enact overt or de facto VBAC bans. As a result, the rate at which VBAC was attempted fell from 26% in the early 1990s to 8.5% in 2006. [4]

In March 2010, the National Institutes of Health met to consolidate and discuss the overall up-to-date body of VBAC scientific data and concluded, "Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision." [5] Simultaneously, the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality reported that VBAC is a reasonable and safe choice for the majority of women with prior caesarean and that there is emerging evidence of serious harms relating to multiple caesareans. [14] In July 2010, The American Congress of Obstetricians and Gynecologists (ACOG) similarly revised their own guidelines to be less restrictive of VBAC, stating, "Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans." [20] and this is also the current position of the Royal College of Obstetricians and Gynaecologists in the UK.

Enhanced access to VBAC has been recommended based on the most recent scientific data on the safety of VBAC as compared to repeat caesarean section, including the following recommendation emerging from the NIH VBAC conference panel in March 2010, "We recommend that hospitals, maternity care providers, health care and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor." [5] The U.S Department of Health and Human Services' Healthy People 2020 initiative includes objectives to reduce the primary caesarean rate and to increase the VBAC rate by at least 10% each. [23]

The American Congress of Obstetricians and Gynecologists (ACOG) modified the guidelines on vaginal birth after previous Caesarean delivery in 1999, 2004, and again in 2010. [11] In 2004, this modification to the guideline included the addition of the following recommendation:

Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care. [11]

In 2010, ACOG modified these guidelines again to express more encouragement of VBAC, but maintained it should still be undertaken at facilities capable of emergency care, though patient autonomy in assuming increased levels of risk should be respected. [4]

The recommendation for access to emergency care during trial of labor has, in some cases, had a major impact on the availability of VBACs to birthing mothers in the US. For example, a study of the change in frequency of VBAC deliveries in California after the change in guidelines, published in 2006, found the VBAC rate fell to 13.5% after the change, compared with 24% VBAC rate before the change. [24] The new recommendation has been interpreted by many hospitals as indicating a full surgical team must be standing by to perform a Caesarean section for the full duration of a VBAC woman's labor. Hospitals that prohibit VBACs entirely are said to have a 'VBAC ban'. In these situations, birthing mothers are forced to choose between having a repeat Caesarean section, finding an alternate hospital in which to deliver their babies or attempting delivery outside the hospital setting. [25]

Most recently, enhanced access to VBAC has been recommended based on updated scientific data on the safety of VBAC as compared to repeat caesarean section, including the following recommendation emerging from the NIH VBAC conference panel in March 2010, "We recommend that hospitals, maternity care providers, health care and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor." [5] The U.S Department of Health and Human Services' Healthy People 2020 initiative includes objectives to reduce the primary cesarean rate and to increase the VBAC rate by at least 10% each. [7]

Position statements

ACOG recommends that obstetricians offer most women with one prior cesarean section with a low-transverse incision a trial of labor (TOLAC) and that obstetricians should discuss the risks and benefits of VBAC with these patients. [4]

Court case

Pemberton v. Tallahassee Memorial Regional Center , 66 F. Supp. 2d 1247 (N.D. Fla. 1999), is a case in the United States regarding reproductive rights. Pemberton had a previous Caesarean section (vertical incision), and with her second child attempted to have a VBAC. [26] When a doctor she had approached about a related issue at the Tallahassee Memorial Regional Center found out, he and the hospital sued to force her to get a c-section. The court held that the rights of the fetus at or near birth outweighed the rights of Pemberton to determine her own medical care. [27] [28] She was physically forced to stop laboring, and taken to the hospital, where a c-section was performed. [26] Her suit against the hospital was dismissed. [26] The court held that a cesarean section at the end of a full-term pregnancy was here deemed to be medically necessary by doctors to avoid a substantial risk that the fetus would die during delivery due to uterine rupture, a risk of 4–6% according to the hospital's doctors and 2% according to Pemberton's doctors. Furthermore, the court held that a state's interest in preserving the life of an unborn child outweighed the mother's constitutional interest of bodily integrity. [29] The court held that Roe v. Wade was not applicable, because bearing an unwanted child is a greater intrusion on the mother's constitutional interests than undergoing a cesarean section to deliver a child that the mother affirmatively desires to deliver. The court further distinguished In re A.C. by stating that it left open the possibility that a non-consenting patient's interest would yield to a more compelling countervailing interest in an "extremely rare and truly exceptional case." The court then held this case to be such. [26] [30]

VBAC versus no previous Caesarean section

VBAC, compared to vaginal birth without a history of Caesarean section, confers an increased risks for placenta previa, placenta accreta, prolonged labor, antepartum hemorrhage, uterine rupture, preterm birth, low birth weight, and stillbirth. However, some risks may be due to confounding factors related to the indication for the first caesarean, rather than due to the procedure itself. [31]

See also

Related Research Articles

<span class="mw-page-title-main">Caesarean section</span> Surgical procedure to deliver a baby through an incision in the mothers abdomen

Caesarean section, also known as C-section, cesarean, or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would put the mother or child at risk. Reasons for the operation include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, shoulder presentation, and problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-section may be possible. The World Health Organization recommends that caesarean section be performed only when medically necessary.

<span class="mw-page-title-main">Childbirth</span> Conclusion of the human pregnancy with the expulsion of a fetus from mothers womb

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In developed countries, most deliveries occur in hospitals, while in developing countries most are home births.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

<span class="mw-page-title-main">External cephalic version</span> Process by which a breech baby can sometimes be turned from buttocks or foot first to head first

External cephalic version (ECV) is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first. It is a manual procedure that is recommended by national guidelines for breech presentation of a pregnancy with a single baby, in order to enable vaginal delivery. It is usually performed late in pregnancy, that is, after 36 gestational weeks, preferably 37 weeks, and can even be performed in the early stages of childbirth.

<span class="mw-page-title-main">Umbilical cord prolapse</span> Complication of pregnancy where the umbilical cord slips out of the uterus prior to birth

Umbilical cord prolapse is when the umbilical cord comes out of the uterus with or before the presenting part of the baby. The concern with cord prolapse is that pressure on the cord from the baby will compromise blood flow to the baby. It usually occurs during labor but can occur anytime after the rupture of membranes.

Labor induction is the process or treatment that stimulates childbirth and delivery. Inducing (starting) labor can be accomplished with pharmaceutical or non-pharmaceutical methods. In Western countries, it is estimated that one-quarter of pregnant women have their labor medically induced with drug treatment. Inductions are most often performed either with prostaglandin drug treatment alone, or with a combination of prostaglandin and intravenous oxytocin treatment.

A hysterotomy is an incision made in the uterus. This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester and delivering the fetus during caesarean section. It is also used to gain access and perform surgery on a fetus during pregnancy to correct birth defects, and it is an option to achieve resuscitation if cardiac arrest occurs during pregnancy and it is necessary to remove the fetus from the uterus.

<span class="mw-page-title-main">Postpartum infections</span> Human disease

Postpartum infections, also known as childbed fever and puerperal fever, are any bacterial infections of the female reproductive tract following childbirth or miscarriage. Signs and symptoms usually include a fever greater than 38.0 °C (100.4 °F), chills, lower abdominal pain, and possibly bad-smelling vaginal discharge. It usually occurs after the first 24 hours and within the first ten days following delivery.

<span class="mw-page-title-main">Placental abruption</span> Medical condition

Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.

Antepartum bleeding, also known as antepartum haemorrhage (APH) or prepartum hemorrhage, is genital bleeding during pregnancy after the 28th week of pregnancy up to delivery.

Cervical dilation is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically or medically.

<span class="mw-page-title-main">Uterine rupture</span> Medical condition

Uterine rupture is when the muscular wall of the uterus tears during pregnancy or childbirth. Symptoms, while classically including increased pain, vaginal bleeding, or a change in contractions, are not always present. Disability or death of the mother or baby may result.

<span class="mw-page-title-main">Prelabor rupture of membranes</span> Breakage of the amniotic sac before the onset of labour

Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labour. Women usually experience a painless gush or a steady leakage of fluid from the vagina. Complications in the baby may include premature birth, cord compression, and infection. Complications in the mother may include placental abruption and postpartum endometritis.

<span class="mw-page-title-main">Placenta accreta spectrum</span> Medical condition

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium. Three grades of abnormal placental attachment are defined according to the depth of attachment and invasion into the muscular layers of the uterus:

  1. Accreta – chorionic villi attached to the myometrium, rather than being restricted within the decidua basalis.
  2. Increta – chorionic villi invaded into the myometrium.
  3. Percreta – chorionic villi invaded through the perimetrium.

Caesarean delivery on maternal request (CDMR) is a caesarean section birth requested by the pregnant woman without a medical reason.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, as it is correlated with lower morbidity and mortality than caesarean sections (C-sections), though it is not clear whether this is causal.

<span class="mw-page-title-main">Shoulder presentation</span> Childbirth in which the arm, shoulder, or trunk emerges first

In obstetrics, a shoulder presentation is a malpresentation at childbirth where the baby is in a transverse lie, thus the leading part is an arm, a shoulder, or the trunk. While a baby can be delivered vaginally when either the head or the feet/buttocks are the leading part, it usually cannot be expected to be delivered successfully with a shoulder presentation unless a cesarean section (C/S) is performed.

Trial of labor after caesarean (TOLAC) is the term for an attempted birth in a patient who has had a previous caesarean section. It may result in a successful VBAC (vaginal birth after caesarean) or a repeat caesarean section. In approximately 20-40% of TOLACs, a caesarean is performed. TOLAC is recommended when a patient has had one previous caesarean section using a low transverse uterine incision. The main risks of TOLAC are emergency caesarean section and uterine rupture.

<span class="mw-page-title-main">Operative vaginal delivery</span>

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

<span class="mw-page-title-main">Uterine niche</span> A medical disorder of the uterus

A uterine niche, also known as a Cesarean scar defect or an isthmocele, is an indentation of the myometrium at the site of a cesarean section with a depth of at least 2 mm.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 Birth after Previous Caesarean Birth (PDF). Green-top Guideline No. 45. Royal College of Obstetricians and Gynaecologists. October 2015.
  2. 1 2 "Vaginal Birth after Cesarean (VBAC)". American Pregnancy Association. Archived from the original on 2012-06-21. Retrieved 2012-06-16.
  3. 1 2 3 "Vaginal birth after C-section (VBAC) guide". Mayo Clinic. 9 February 2005. Archived from the original on 23 December 2005.
  4. 1 2 3 4 5 6 7 8 "Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery". Obstetrics & Gynecology. 116 (2): 450–463. August 2010. doi:10.1097/AOG.0b013e3181eeb251. PMID   20664418.
  5. 1 2 3 4 5 "National Institutes of Health Consensus Development Conference Statement: Vaginal Birth After Cesarean: New Insights March 8–10, 2010". Obstetrics & Gynecology. 115 (6): 1279–1295. June 2010. doi:10.1097/AOG.0b013e3181e459e5. PMID   20502301.
  6. ↑ "Vaginal Birth After Cesarean: New Insights". Agency for Healthcare Research and Quality. March 2010. Archived from the original on 14 April 2010.
  7. 1 2 3 "Maternal, Infant, and Child Health—Healthy People". Healthypeople.gov. 13 September 2012.
  8. ↑ Habak, Patricia J.; Kole, Martha (2024). "Vaginal Birth After Cesarean Delivery". StatPearls. StatPearls Publishing. PMID   29939621.
  9. ↑ "Guideline Synthesis: Vaginal Birth After Cesarean (VBAC)". National Guideline Clearinghouse. Archived from the original on 2012-03-20. Retrieved 2012-06-16.
  10. ↑ Naji, Osama; Abdallah, Yazan; Paterson-Brown, Sara (2010). "Cesarean Birth: Surgical Techniques". The Global Library of Women's Medicine. doi:10.3843/GLOWM.10133.
  11. 1 2 3 American Congress of Obstetricians and Gynecologists (ACOG). "Guideline on Vaginal birth after previous cesarean delivery". guideline.gov. Archived from the original on 2008-01-15. Retrieved 2008-02-09.
  12. ↑ Vaginal birth after caesarean (VBAC) (PDF). Queensland Clinical Guidelines. Queensland Health. September 2020.
  13. ↑ Baradaran, Kimya (31 March 2021). "Risk of Uterine Rupture with Vaginal Birth after Cesarean in Twin Gestations". Obstetrics and Gynecology International. 2021: 1–5. doi: 10.1155/2021/6693142 . PMC   8032534 . PMID   33868405.
  14. 1 2 3 "Vaginal Birth After Cesarean: New Insights". Agency for Healthcare Research and Quality. March 2010. Retrieved 2012-06-16.
  15. ↑ "Thinking about VBAC - English" (PDF). www.ontariomidwives.ca.
  16. ↑ Menacker, Fay; Hamilton, Brady E. (March 2010). "Recent trends in cesarean delivery in the United States". NCHS Data Brief (35): 1–8. PMID   20334736.
  17. ↑ "Cesarean births, repeat (percent)—Health Indicators Warehouse". Healthindicators.gov. Archived from the original on 2012-03-23. Retrieved 2011-08-15.
  18. ↑ "Rates for Total Cesarean Section, Primary Cesarean Section and Vaginal Birth After Cesarean Section (VBAC), United States, 1989–2006" (PDF). Childbirth Connection. January 2008. Archived from the original (PDF) on 17 December 2008.
  19. 1 2 McMahon, Michael J.; Luther, Edwin R.; Bowes, Watson A.; Olshan, Andrew F. (5 September 1996). "Comparison of a Trial of Labor with an Elective Second Cesarean Section". New England Journal of Medicine. 335 (10): 689–695. doi:10.1056/NEJM199609053351001. PMID   8703167.
  20. 1 2 "Ob Gyns Issue Less Restrictive VBAC Guidelines" (Press release). The American College of Obstetricians and Gynecologists. 21 July 2010. Archived from the original on 5 June 2012.
  21. ↑ Centers for Disease Control and Prevention (CDC) (21 April 1995). "Rates of cesarean delivery – United States, 1993". Morbidity and Mortality Weekly Report. 44 (15): 303–307. PMID   7708041.
  22. ↑ "Vaginal birth after previous cesarean delivery". International Journal of Gynecology & Obstetrics. 66 (2): 197–204. August 1999. doi:10.1016/S0020-7292(99)80021-6.
  23. ↑ "2020 Topics & Objectives: Maternal, Infant, and Child Health". U.S. Department of Health and Human Services. Retrieved 2012-06-16.
  24. ↑ Zweifler, John; Garza, Alvaro; Hughes, Susan; Stanich, Matthew A; Hierholzer, Anne; Lau, Monica (May 2006). "Vaginal Birth After Cesarean in California: Before and After a Change in Guidelines". Annals of Family Medicine. 4 (3): 228–234. doi:10.1370/afm.544. PMC   1479438 . PMID   16735524.
  25. ↑ Rubin, Rita (24 August 2005). "Battle lines drawn over C-sections". USA Today. Archived from the original on 13 February 2006.
  26. 1 2 3 4 "Pemberton v. TALLAHASSEE MEMORIAL REGIONAL MEDICAL, 66 F. Supp. 2d 1247 (N.D. Fla. 1999)". Justia Law. Retrieved 2023-03-02.
  27. ↑ Kaplan, Margot (2010). ""A Special Class of Persons": Pregnant Women's Right to Refuse Medical Treatment after Gonzalez v. Carhart". Journal of Constitutional Law. 13– via Penn Law Legal Scholarship Repository.
  28. ↑ Pratt, Lisa (2013–2014). "Access to Vaginal Birth after Cesarean Section: Restrictive Policies and the Chilling of Women's Medical Rights During Childbirth". William & Mary Journal of Race, Gender, and Social Justice. 20: 119.
  29. ↑ U.S. District Court, N.D. Florida, Tallahassee Division (1999). "Pemberton v. Tallahassee Memorial Regional Center". West's Federal Supplement. 66: 1247–1257. ISSN   1047-7306. PMID   11868571.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  30. ↑ Roth, Louise (2021). The Business of Birth: Malpractice and Maternity Care in the United States. New York: New York University Press. pp. 189–213.{{cite book}}: CS1 maint: date and year (link)
  31. ↑ Kennare, Robyn; Tucker, Graeme; Heard, Adrian; Chan, Annabelle (February 2007). "Risks of Adverse Outcomes in the Next Birth After a First Cesarean Delivery". Obstetrics & Gynecology. 109 (2, Part 1): 270–276. doi:10.1097/01.AOG.0000250469.23047.73. PMID   17267823.
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