What You Need to Know About Cesarean Birth

Cesarean section (c-section) is the surgical delivery of a baby through an incision (a cut) in the abdomen and the uterus. It can be a lifesaving operation when either you or your baby experience certain problems before or during labor and delivery. There is a chance you might deliver your baby surgically, but you probably won't know for sure until the last minute.

If you're like most women, you probably won't give cesarean section much thought unless your pregnancy is high risk. But did you know that one in five babies in the United States is delivered by c-section? Also, most women who have c-sections do not know they'll deliver this way ahead of time.

Taking the time now to learn what c-sections are, why they are performed and what recovery involves can make the whole process easier to cope with if you are one of the 20 percent of mothers who deliver by c-section.

Why Do Some Women Need C-Sections?
C-sections are performed when the health of the baby or mother is at risk. Some of the situations that could put you or your baby at risk include:

• Problems with the umbilical cord. Sometimes the umbilical cord falls into the vagina or is pinched or compressed.
• Bleeding from the placenta.
• Abnormal pelvic structure in the mother. For instance, some women have had a serious injury to the pelvis, or they were born with a pelvic defect.
• Serious maternal health problems (such as heart disease or an active herpes infection) when labor would not be safe for either mother or baby.
• Delivery is advised but the mother is not in labor. Reasons include infection or severe preeclampsia.
• Failure of labor to progress. About one-third of c-sections are done because labor progresses too slowly or stops.
• Shoulder or breech presentation. The baby's buttocks or feet enter the birth canal first, instead of the head.
• More than one baby. Many women having twins are able to deliver vaginally, but the risk increases with the number of babies.
• Fetal distress. The baby may show signs of distress such as slowing of heart rate or acid in the blood before vaginal delivery can be completed quickly.
• Fetal illness. Babies diagnosed prenatally with certain medical conditions, such as spina bifida (a birth defect that affects the backbone and sometimes the spinal cord), may need to be delivered by c-section.

But keep in mind that having any of these conditions does not necessarily mean you will have to have a c-section - €”it just increases the chance that you will have one.

What Will Happen if I Need a C-Section?
C-sections usually are performed in an operating room set aside for these special surgeries. Either general or regional anesthesia (epidural or spinal) is used. If your c-section is an emergency procedure, general anesthesia may be needed and you will be asleep during the delivery. If spinal or epidural anesthesia is used, you will be awake for the birth of your baby, but numb from pain from below your breasts to your toes.

A thin tube called a catheter is placed into your bladder to drain urine during surgery, and a needle is inserted in a vein in your hand or arm to give you fluids during the operation and medications if needed. After your abdomen is shaved and washed, and you are numb or asleep, the doctor makes the first incision. This is usually a horizontal or "bikini" cut just above your pubic bone, although sometimes a vertical incision is needed (depending upon the position of the baby or the placenta). The second incision is made in the wall of the uterus. The doctor can then open the amniotic sac and remove the baby. You may feel some tugging, pulling and some pressure. Next the doctor detaches and removes the placenta. Then the incisions in the uterus and abdomen are closed.

The procedure usually takes about 45 minutes to an hour. The baby is born in the first 5 to 10 minutes. Then the incision is repaired. If you're feeling up to it, you may be able to hold your baby in the delivery room, once the baby's nose and mouth have been suctioned and he or she has been checked.

Physical and emotional recovery from a cesarean delivery takes more time than recovery from a vaginal delivery. You can expect to spend two to four days in the hospital, and four to six weeks at home before feeling back to normal. You'll need to take things as slowly as you can and get as much help as possible until you are back on your feet again.

Are There Risks Associated With C-Sections?
Cesarean birth carries greater risk for both the mother and the baby than a vaginal delivery. Some of the increased risks for the mother include possible infection of the uterus and nearby pelvic organs; increased bleeding; blood clots in the legs, pelvic organs and sometimes the lungs; and, in very rare situations, death. For babies, there is the risk of being born prematurely if the due date is not accurately calculated. This can mean difficulty breathing (respiratory distress) and low birthweight. The baby also may be sluggish as a result of the anesthesia. A cesarean birth also is more painful, is more expensive, and takes longer to recover from than a vaginal birth.

Are All C-Sections Necessary?
Some health care experts believe that half of all c-sections performed in the U.S. are unnecessary, and you may have heard publicity about the high c-section rate in the U.S. So why are they so common? Many people suspect doctors' motives, including fear of malpractice suits and convenience. Others dispute these accusations, point to the lifesaving aspects of c-sections, and argue it is better to be safe than sorry.

Unless there are serious medical risks, fewer than half of women who have previously had c-sections need them again. If you've had a c-section before, and you want to try to deliver your next baby vaginally, be sure to discuss VBAC (vaginal birth after cesarean) with your health care provider.

It is important to keep in mind that a cesarean section delivery is major surgery and should be done only when the health of the mother or baby is at risk. It should not be considered an option for the convenience of the doctor or the parents, or for any other nonmedical reason.

Is There Anything I Can Do to Avoid Having a C-Section?
Since no one can plan for a "perfect" delivery, and most c-sections are unexpected, it is unlikely there is anything special you can do to avoid a c-section. You can, however, take good care of yourself during your pregnancy so that you have the best chance of delivering a healthy baby. Some of these things may help you avoid the need for a cesarean:

Get early prenatal care. When you choose a hospital or health care provider, ask about their cesarean rate. Look for rates around 15 percent. If you've already had a c-section, ask how many of the provider's patients try to deliver vaginally with later babies.

Stay fit and maintain a healthy lifestyle during your pregnancy. Watch your weight—too much weight gain can increase the baby's size, making vaginal delivery difficult.

Watch for any signs of trouble during pregnancy and alert your provider immediately.

During early labor, drink plenty of fluids, and suck on ice chips during active labor. Remember to urinate, too! Walk around as much as possible or change positions frequently during labor to see what is most comfortable for you.

Remember, by learning all you can about cesarean birth, you'll know when it is appropriate and what to expect. And if you do need one, try not to feel disappointed. While most mothers would prefer a vaginal birth, virtually all would agree that having a healthy baby and being a healthy mom are much more important than the method of delivery.

from: http://www.marchofdimes.com/pnhec/240_1031.asp

A C-section delivery is performed when a vaginal birth is not possible or is not safe for the mother or child.

Surgery is usually done while the woman is awake but anesthetized from the chest to the legs by epidural or spinal anesthesia. An incision is made across the abdomen just above the pubic area. The uterus is opened, the amniotic fluid is drained, and the baby is delivered.

The baby's mouth and nose are cleared of fluids, and the umbilical cord is clamped and cut. The baby is handed to the pediatrician or nurse who will make sure that breathing is normal. The mother is awake and she can hear and see her baby.

Due to a variety of medical and social factors, C-sections have become fairly common -- about 26% of all births in the United States in 2002 were C-sections.

Indications

The decision to have a C-section delivery can depend on the obstetrician, the delivery location, and the woman's past deliveries or medical history. Some of the main reasons for C-section instead of vaginal delivery include the following:

Reasons related to the baby:

• Developmental abnormalities of the fetus, such as hydrocephalus or spina bifida
• Abnormal fetal heart rate pattern
• Abnormal position of the baby within the uterus, such as crosswise (transverse) or buttocks-first (breech)
• Multiple babies within the uterus (triplet and some twin pregnancies)

Reasons related to the mother:

• Extreme maternal illness, such as heart disease, toxemia, preeclampsia or eclampsia
• Active genital herpes infection
• Maternal HIV infection
• Previous surgery in the uterus, including myomectomy and previous C-sections

Problems with labor or delivery:

• Prolonged or arrested labor
• Very large baby (macrosomia)
• Cephalopelvic disproportion (baby's head is too large to pass through mother's pelvis)

Problems with the placenta or unbilical cord:

• Umbilical cord prolapse (the umbilical cord comes through the cervix)
• Placenta attached in abnormal location (placenta previa) or prematurely separated from uterine wall (placenta abruptio)

Risks

C-sections have become very safe procedures. The rate of serious complications, such as maternal death related to C-section delivery, is extremely low.

However, certain risks are higher after C-section than after vaginal delivery:

Risks due to anesthesia:

• Reactions to medications
• Problems breathing

Risks related to surgery:

• Bleeding
• Infection

Additional risks specific to C-section:

• Infection of the bladder or uterus
• Injury to the urinary tract
• Injury to the baby

Expectations after surgery

Most mothers and infants recover well, with few problems.

Women who have C-section deliveries can often have a normal vaginal delivery with later pregnancies, depending on the type of C-section performed and the reason the C-section was performed.

About two-thirds of women who attempt a vaginal birth after cesarean (VBAC) delivery are successful. However, there is a small risk of uterine rupture associated with VBAC attempts, which can endanger the mother and the baby. It is important to discuss the benefits and risks of VBAC with your obstetric health care provider.

Convalescence

The average hospital stay after C-section is 2 to 4 days. Recovery takes longer than it would from a natural birth. Walking is encouraged the day of surgery to speed recovery. Pain can be managed with oral medications.

from: http://www.nlm.nih.gov/medlineplus/ency/article/002911.htm

Facts:

A cesarean section is major abdominal surgery. When a cesarean is necessary, it can be a life saving technique for both mother and infant.

The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent.

In the past twenty years, the cesarean section rates have nearly quintupled in the US to 23.8% in 1989 and nearly quadrupled in Canada to 18.3% in 1987-8.

A cesarean section poses documented medical risks to the mother's health, including infections, hemorrhage, transfusion, injury to other organs, anesthesia complications, psychological complications, and a maternal mortality two to four times greater than that for a vaginal birth.

An elective cesarean section increases the risk to the infant of premature birth and respiratory distress syndrome, both of which are associated with multiple complications, intensive care and burdensome financial costs. Even mature babies, the absences of labor increases the risk of breathing problems and other complications.

Cesareans can delay the opportunity for early mother-newborn interaction, breastfeeding and the establishment of family bonds.

In the US and Canada, over one-third of all cesareans are repeat cesareans. The American College of Obstetricians and Gynecologists (ACOG) recommends that the concept of routine repeat cesarean be replaced by a specific indication for surgery, and that most women can be counseled and encouraged to labor and have a vaginal birth after a cesarean (VBAC).

In 1989, 81.5% of all US women with a previous cesarean had a repeat cesarean. The VBAC rate was 18.5%. The VBAC rate is greater in every eastern and western European country.

The "once a cesarean, always a cesarean rule is outdated now that most of uterine incisions are low and horizontal and the risk of rupture of the old scar is almost nonexistent. A review of all VBAC literature from 1985-1990 found a rupture rate of 0.22% for low transverse scars in 22,000 planned labors after cesarean. (In developed nations the rupture rate was 0.18%.) By comparison, the incidence of other childbirth emergencies, such as prolapsed cord, placental separation, or sudden fetal distress is 1-3%.

ACOG states that the hospital requirements for VBAC are the same standards for all obstetrics. These include the capacity to respond to acute obstetric emergencies by performing a cesarean within 30 minutes. However, many hospitals in North America that offer maternity care do not allow or encourage women to labor and have a VBAC.

In a review of all the medical reports published on VBAC from 1926-1990, 75% of all women who planned labor after a cesarean gave birth vaginally. Several medical studies record VBAC rates of over 90%.

The latest statistics indicate that 967,000 cesareans were performed in the US in 1989. The Public Health Citizen's Research Group estimates that over one-half the cesareans performed in 1987 were unnecessary and resulted in 25,00 serious infections, 1.1 million extra hospital days and a cost of over $1 billion. About 500 women a year die from bleeding, infections and other complications of cesarean sections, although these may be related to the reasons the operation was performed and not just to the procedure itself.

A cesarean costs nearly twice as much as a vaginal birth ($7,186 average vs. $4,334 average in 1989 in the US). It has been estimated that in Quebec, Canada, if the current rate of cesareans (18.8%) were reduced to that of Finland (11.9%), costs incurred by the provincial health care system could be reduced approximately $19 million per year.

The four most common medical causes contributing to the increase in cesarean section rates in North America are: routine repeat cesareans; dystocia (non-progressive labor); breech presentation; and fetal distress. Some reports suggest that more careful diagnosis and management of dystocia could halve the primary section rate. Combined with fewer cesareans for breech presentation (along with more cephalic versions), careful diagnosis of fetal distress and active encouragement of VBAC, these efforts have resulted in lowering cesarean rates to less than 12% in various parts of the world.
Up to 77% of women for whom the indication for cesarean delivery was a non-progressive labor (sometimes diagnosed as cephalopelvic disproportion or CPD) and who tried labor again, had a VBAC for a subsequent birth. Approximately one-third of these women gave birth to babies that were larger than their previous "CPD" baby.

ACOG states that a woman with two or more previous cesareans deliveries with low transverse incisions who wishes to plan a VBAC should not be discouraged from doing so in the absence of contraindications.

Cesarean rates are influenced by non-medical factors. Rates are higher for women who have private medical insurance, are private rather than public clinic patients, are older, are married, have higher levels of education and are in a higher socio-economic bracket.

In 1989, a medical study done in Houston, Texas, concluded that epidural analgesia is associated with significant increases in the incidence of cesarean section for dystocia in women having their first labor.

Cesarean sections are sometimes performed for other than maternal or fetal well-being, such as avoidance of patient pain, patient or provider convenience, provider legal concerns or provider financial incentives.

Although rare, there have been reports of court-ordered cesareans performed on women against their will. One such case was appealed, supported by 118 US organizations, claiming that the decision was unconstitutional and raises complex legal, moral and religious issues. The appeal judge issued a forceful decision asserting that "in virtually all cases the question of what is to be done is to be decided by the patient -the pregnant woman- on behalf of herself and her fetus."

In March 1990, an ACOG survey of 2,213 obstetricians documented the changing attitude about VBAC in the US. The survey reported that women under the care of younger physicians and physicians in practice for fewer years were more likely to accept the option of VBAC than women under the care of older physicians and those in practice the longest.

Of 11,814 women admitted for labor and delivery and attended by midwives to 84 free standing birth centers in the US, 15.8% were transferred to the hospital and 4.4% had a cesarean section. Although the women were lower than average risk of a poor pregnancy outcome, their cesarean rate is one-fifth of the national average.

from: http://www.childbirth.org/section/CSFact.html

C-sections and partners:
Most hospitals will allow you to go into the operating room with your partner, or if you feel unable to, she may be accompanied by one other person (some hospitals will allow two if one is the doula).
Contrary to popular belief, most people do not faint in the operating room. The mother will provided a drape to block her view of the surgery, feel free to stay behind the curtain with her if you are worried. Just being there for her and telling her what is going will help her. Sometimes the doctor will allow you to cut the cord, carrying the baby to the nursery, and take pictures. Make sure that you ask about these particular things.

Recovery:
Everyone's recovery will be different, depending on your age, body type, and general health. However, some basics of recovery will be to remember that you have just had major abdominal surgery as well as given birth to a new baby. You may be plagued with gas pains from being opened, incisional pain, uterine contractions (your uterus will still need to work to get back to it's original shape). You may be extremely tired from medications, labor (if you had one), or just in general. Your staples will usually be removed about 4-7 days postpartum. Try to take everything easy. Do as little as possible, although walking as soon as possible is very helpful in your recovery. The rule of thumb is to not lift anything heavier than your baby. When you get home, take the steps only once a day (if at all). Make a nest on the couch and nap there during the day. Get as much help as you can with your cleaning, food preparations, and other children.

You can start doing breathing exercises the first day in the hospital, someone will show you how. Then each day you can gradually find small exercises to do to get back into shape. Do not return to your previous exercise routine without permission of your care provider. Overdoing it will only slow your recovery.

By the end of six weeks, some people say they are feeling pretty good, although still dealing with some pain and sleeplessness. After this period you can usually resume most activities (Some doctors will allow you to drive after about 2 weeks, others request that you wait the entire 6.).

Procedure:
Some of these may go in a different order, and a few left out, but these are the basics:

A catheter inserted to collect urine

An intravenous line inserted

An antacid for your stomach acids

Monitoring leads (heart monitor, blood pressure)

Anesthesia

Anti-bacterial wash of the abdomen, and partial shaving of the pubic hair

Skin Incision (vertical or midline(most common))

Uterine Incision

Breaking the Bag of Waters

Disengage the baby from the pelvis

BIRTH!!!! (Accomplished by hand, forceps, or vacuum extractor)

Cord Clamping and cutting

Newborn Evaluation

Placenta removed and the uterus repaired

Skin Sutured (Usually the top layers will be stapled and removed within 2 weeks.)

You will be moved to the Recovery Room (If the baby is able s/he can go with you.)

How long will it be until my baby is born?

It is generally 5 minutes from the time that they make the initial incision until the baby is born. The rest of the surgery will take between 30 and 40 minutes, including repair.

from: www.childbirth.org

VBAC

What is a VBAC?

Vaginal Birth After Cesarean is what VBAC stands for. It is a vaginal birth after one or more cesareans. More than 80% of women will be able to have a VBAC.

According to Midwifery Today (most recent issue, Winter No 36 page 47) ACOG recently updated their opinion on VBAC and stated "VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk". The Guidelines can be obtained from: ACOG, 409 12th St SW, Washington DC 20024.

Why would I want a vaginal birth?

There are many reasons that you may want a vaginal birth after a cesarean. Some may be medical and some may be emotional. Others may be financial or in terms of recovery. Here are some brief lists of the benefits to the mother and baby of a vaginal birth.

Mother:

• Prevention of Death from surgery
• Prevention of lesser complications from surgery
• Prevention of blood loss
• Prevention of infection
• Prevention of injury (bowel, urinary tract, etc.)
• Prevention of blood clots in the legs
• Prevention of feelings of guilt or inadequacy that surgery sometimes causes
• Breastfeeding is generally easier after a vaginal birth
• The cost of a vaginal birth is about $3,000 less

Baby:

• Prevention of Iatrogenic Prematurity (meaning surgery was done, because of an error in guessing a due date)
• Reduction in the cases of Persistent Pulmonary Hypertension
• Labor prepares the baby for extrauterine life
• Prevention of surgery related fetal injuries (lacerations, broken bones)
• VBAC results in fewer fetal deaths than elective repeat cesareans

What about rupture of the uterus?

This is a common fear among women who have had a previous cesarean. Most of this fear dates back to when the incisions of the original cesarean were of the classical variety (vertical incisions), nowadays most incisions are the low transverse type. There are two types of uterine rupture: complete and incomplete.

Complete uterine rupture is very unlikely today, for a variety of reasons. One is that when we use Pitocin, if needed, during a labor, we regulate the amount that goes in. In other times it was given IV to a woman and allowed to flow freely. These have also decreased due to some obstetrical practices being abandoned, like high forceps, internal version, etc. And the final reason is because of the rarity of the classical incision. A complete rupture occurs in much less than 1% of women attempting VBAC.

Incomplete rupture occurs about 1-2% of the time. However, usually these women are asymptomatic, and neither mother or infant require any assistance.

Golan published a study in 1980, where there were 93 ruptures of the uterus. 61 of those ruptures occurred in a normal uterus (never had an incision), and 32 of them had had previous incisions. There were 9 maternal deaths from the ruptures, but they were all from the group that had not had previous cesareans. For more information, see Studies on VBAC.

Pregnancy After Cesarean Section

You may be worried to be pregnant again, and really don't know where to turn for information or support. You may wonder what you can do to increase your chances of a successful VBAC. There are several things you can do, they are listed below in Preparing for your VBAC. Basically, the same rules of pregnancy apply, eat well, exercise, educate yourself, and develop a good birth team. Take responsibility for your care.

Labor After a Cesarean

The time has come. Labor has arrived! What will it hold for you? Many women are very emotional about the labor, and rightly so. Critical times may be the place where you got "stuck" at the last birth, when your water breaks, getting to the hospital, or any other time. Support is critical, turn to those around you. Here are some questions that many women have about laboring with a VBAC.
What if I had a cesarean because my pelvic bones were too small?

Most women do not truly have pelvic bones that are too small, unless you have suffered a pelvic fracture or had polio. Women with a pelvis to small to give birth vaginally are truly few and far between. Many women go ahead to deliver vaginally the next time, and have a bigger baby than the first!

What if the baby is large?

The pelvis and the baby's head are not rigid structures. Both mold and change shape to allow the birth to occur. There are certain postures that you can assume to help your pelvis expand (For example: Squatting opens the outlet of the pelvis by 10%.) The American College of OB/GYNs (ACOG) has stated that the effects of labor with a baby of more than 4,000 grams (8 3/4 lbs) has not been substantiated. However, in one study, 67% of babies weighing more than 4,000 grams were born vaginally, even when over 50% of these mothers had had previous cesareans for failure to progress.

What if I have had Herpes?

In years past, many women were delivered by cesarean for a history of genital herpes. Doctors did cultures in the last weeks of pregnancy to determine if the infection was active. ACOG has determined and recommended that unless there is a visible lesion at the time of birth, a vaginal birth is acceptable.

What if I have had more than one cesarean?

From the Guide to Effective Care in Pregnancy and Childbirth:"The available data on outcomes after a trial of labour in women who have had more than one previous caesarean section show that the overall vaginal delivery rate is little different from that seen in women who have had only one previous caesarean section."... and also ... "the available evidence does not suggest that a woman who has had more than one previous ceasarean section should be treated any differently for the woman who has had only one caesarean section".

What if the other cesarean was for fetal distress?

True fetal distress is rare, and only a handful of cesareans are done for fetal distress. One study indicates that fetal distress only occurs in 1.5% of all VBAC attempts (Finley, Gibbs), while another showed that of mothers who had a primary cesarean for fetal distress, the second labor had 3% of those mothers with fetal distress (Paul, Phelan, Yeh).

This brings us to fetal monitoring. In a normal, low risk pregnancy, fetal monitoring has not been shown to improve maternal or fetal outcomes, rather it only serves to increase the cesarean rates. Some care providers insist on continuous electronic fetal monitoring for VBAC clients. This is something that you need to research beforehand, and decide if it is something you want and can live with.

Specifications for VBAC

Who is a candidate for VBAC?

The general guidelines for VBAC are:

• Low transverse incisions on both the abdomen and uterus
• Adequate pelvis (See Above)
• Willingness to prepare for VBAC

Preparing for your VBAC

There are many things that you should do to prepare yourself for a VBAC. Some are mental, emotional, physical and general preparations for your VBAC.

Information. Get as much of it as you can. Obtain a copy of your medical records from the previous birth( for yourself. Ask your current careprovider to explain anything that you don't understand. Talk to your careprovider, make plans with them (See Birth Plan FAQ). Talk to other people who have been there. Read a lot of books and journals.

Physically you need to prepare your body. Being in good physical condition can help your labor move more quickly as well as speed healing. Regular exercise and special birth exercises are good ways of doing this.

For more information on how to prepare yourself, check out the VBAC Checklist

Birth Alternatives with VBAC

Can I use a midwife?

You certainly can. As we have discussed before, with a few exceptions, VBAC is actually safer than an elective repeat cesarean. Midwives are trained to detect problems and can refer you to their back-up physician, should you need that type of care.

Can I give birth at a birth center?

Once again, this goes back to you and your careprovider.

Can I still have a homebirth?

This is up to you and your careprovider. Most practitioners of homebirth do not see any reason why you cannot have a homebirth VBAC.

What about medications?

Medication is labor and birth is fairly controversial, even without VBAC. When you are talking pain relief medications, you need to think some things through. Unless you do not want them or have a medical reason for not having them, pain relief medications can be used with a VBAC. However, it is important to use them wisely. We know that epidurals can increase the cesarean rate. You may want to consider delaying medications and using non-pharmacological methods of pain relief as long as you possibly can. Some studies indicate that if you delay an epidural past 5 cms then you lose the risk of increased cesarean.

Narcotics are also sometimes used in labor. While these do not have a direct effect on your chances of cesarean, they do have an effect on your mobility and your mind. Some women feel that their minds were clouded when they used narcotics. Often, once you receive a narcotic you are confined to bed, limiting your mobility, which can hinder labor. There are also effects of these drugs on babies that are much more apparent.

Pitocin, used to induce or speed labor, was once controversial in VBAC births. However, in the American College of OB/GYNs VBAC Guidelines it states that pitocin is safe for use with VBAC births, because the risks of uterine rupture is so small.

Resources for VBAC

Research and Books:

Some of these are books, others are journal articles. You can buy most of the books at your local bookstore, or order them online from Childbirth.org. Journal articles can be reviewed at your local library or medical school.

By Nancy Wainer Cohen and Lois J. Estner:
Silent Knife; Open Season; Birth Quake (Coming soon!)

By Bruce Flamm:
Birth After Cesarean

By Johanne C. Walters , Karis Crawford:
Natural Birth After Cesarean: A Practical Guide

By William and Martha Sears:
The Birth Book

By Penny Simkin:
The Birth Partner; Pregnancy, Childbirth and the Newborn (Simkin, Whalley and Keppler)

By Diana Korte and Roberta Scaer:
Good Birth, Safe Birth

By Sheila Kitzinger:
Your Baby, Your Way; Homebirth; Birth Over 35; Complete Book of Pregnancy

By Lynn Madsen:
Rebounding From Childbirth: Towards Emotional Recovery

Journal Articles:

Flamm, BL, JR Goings, NJ Fuelberth, E Fischermann, C Jones, E Hersch. 1987. "Oxytocin During Labor after Previous Cesarean Section:Results of a Multicenter Study." Obstet. Gynecol. 70:709-712.

Public Citizen Health Research Group. 1989. "Unnecessary Cesarean Sections: How to Cure a National Epidemic." Washington, DC

Asakura H & Myers SA. More than one previous cesarean delivery: a 5-year experience with 435 patients. Obstet Gynecol 1995;85:924-9.

Flamm, BL, OW Lim, C. Jones, D. Fallon, LA Newman, and JK Mantis. 1988. "Vaginal Birth After Cesarean Section: Results of a Multicenter Study." Am. J. Obstet. Gynecol. 158:1079-1084.

Finley, BE, and CE Gibbs. 1986. "Emergent Cesarean Delivery in Patients Undergoing a Trial of Labor with a Transverse Lower-segment Scar." Am. J. Obstet. Gynecol. 155;936-939.

Hertitage, CK, MD Cunningham. 1985. "Association of Elective Repeat Cesarean Delivery and Persistent Pulmonary Hypertension of the Newborn." Am. J. Obstet. Gynecol. 152:627-639.

Schreiner, RL, et al. 1982. "Respiratory Distress Following Elective Repeat Cesarean Section." Am. J. Obstet. Gynecol. 143:689-692.

Bowers, SK, et al. 1982. Prevention of Iatrogenic Neonatal Respiratory Distress Syndrome: Elective Repeat Cesarean Section and Spontaneous Labor." Am. J. Obstet. Gynecol. 143:186-189.

Paul, RH, JP Phelan, S Yeh. 1985. Trial os Labor in the Patient with a Prior Cesarean Birth. Am. J. Obstet. Gynecol. 151:297-303.

from: http://www.childbirth.org/section/VBACFAQ.html