Vaginal Birth after Caesarean (VBAC)

Key Messages

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These are the main health messages that should be conveyed to all future and new parents. They have been written in the second person and at a reading level appropriate for the general public so that they can be shared with them directly. They are based on a consensus founded in scientific research and professional practice. Clicking an underlined word or group of words in the text will redirect you to the section in Supporting Evidence that deals with that topic.

key message

Giving birth vaginally after a previous caesarean birth can be a safe alternative to a repeat caesarean birth. This is known as a VBAC.

The benefits of having a VBAC instead of a repeat caesarean birth include:

  • No risk of complications from an abdominal operation.
  • Reduced risk of blood loss.
  • Less pain.
  • Reduced risk of a postpartum fever.
  • Reduced risk of an infection.
  • Being able to walk sooner after birth.
  • A shorter recovery time.
  • Satisfaction of having a vaginal birth.
  • Earlier start to breastfeeding and better success with breastfeeding at three to six to six months.
  • Fewer potential complications for the newborn.

If you are planning to have more children, choosing a VBAC may be the safest option for you. The more caesarean births you have, the more likely you will have problems with the placenta in future pregnancies.


key message

Discuss with your health care provider if a VBAC is right for you.

In order for a VBAC to be safe it is important that:

  • The incision (cut) in your uterus during your last caesarean birth(s) was made in a horizontal direction (across) the lower part of your uterus. The incision in your uterus is not always in the same direction as the incision in your skin. To learn where the incision in your uterus was made, your health care provider can review your health care record from your previous caesarean birth(s).
  • You have not had any surgery (other than your caesarean birth) where an incision was made in your uterus.
  • Your uterus has never ruptured (come apart).
  • The reason you needed to have a caesarean birth the last time is not a reason this time and that there are no other reasons why you should not labour and give birth vaginally.

Risks associated with a VBAC include:

  • Uterine rupture. This involves a tear along the scar on your uterus from your previous caesarean birth(s). If this occurs, an emergency caesarean birth will be done. Uterine rupture can lead to the need for a blood transfusion and/or the removal of your uterus.
  • The need for a repeat, possibly urgent, caesarean birth if there is an urgent health concern during labour.

Risks associated with a VBAC are higher for women who:

  • Have had a caesarean birth less than 18 months ago.
  • Have had more than three caesarean births.
  • Are older than 35 years of age.
  • Have a body mass index (BMI) greater than 30 kg/m2.
  • Are given medication to start (induce) or speed up (augment) their labour.


key message

If you choose to have a VBAC, you and your baby will be monitored closely during labour.

If you choose to have a VBAC, you may still need to have a caesarean birth. For this reason, the Society of Obstetricians and Gynaecologists of Canada (SOGC) does not recommend a home birth for a VBAC. A midwife may still be your primary health care provider if you decide to have a VBAC. If you are interested in a VBAC at home, you should discuss the risks and special considerations with your midwife.

When you are in active labour, your contractions and your baby’s heart rate will be monitored continuously. Your vital signs and your labour progress will also be checked regularly.

A strong support system can be especially helpful if you choose to have a VBAC.

During a VBAC, you may choose your method of non-medical or medical pain relief, including an epidural.


key message

If you choose to have a VBAC, some methods to induce or improve your labour progress are safer than others.

It is safest for you and your baby to go into labour on your own. However, sometimes women need help to start their labour (induction) or to speed up their labour (augmentation).These methods may include:

  • A catheter inserted into cervix to soften and widen it.
  • Small, gradually increasing doses of oxytocin medication given through an intravenous (IV) line.

Oxytocin is a hormone which causes contractions to occur. During a VBAC, it will only be given if necessary as it can increase the risk of uterine rupture.

Please see the Interventions in Labour file for more information on methods of induction and augmentation of labour.


key message

You will be closely monitored after your baby is born if you have VBAC, or if you try to have a VBAC and have a caesarean birth.

Following a VBAC or a trial of labour with a repeat caesarean birth, your health care providers will closely monitor the amount of vaginal bleeding that you have. Uterine rupture, although rare, could still occur. Tell your health care provider if you have an increase in vaginal bleeding after the birth.

Whether you have a VBAC or a caesarean birth, following the birth, talk to your health care provider about your future birthing options. This can help you make decisions in future pregnancies.

key message

Learn more about vaginal birth after caesarean.

You can find out more about VBAC from the following resources. More suggestions can be found in the Resources and Links section.

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Supporting Evidence



The supporting evidence is written in third person and is aimed at prenatal education providers. It is not intended to be shared directly with new and expectant families; it is meant to provide the background information and evidence for the key messages.

About Vaginal Birth after Caesarean (VBAC)

Defining vaginal birth after caesarean

Women who have had a previous caesarean birth may be able to give birth vaginally the next time that they give birth. This is referred to as vaginal birth after caesarean or a VBAC. Women who have had a previous caesarean birth can usually be given the choice to attempt a VBAC or have a repeat caesarean birth, as long as they do not have any medical or obstetrical contraindications that preclude them from giving birth vaginally.1,2,3,4

Considering a VBAC

There are many benefits associated with having a VBAC rather than a repeat caesarean birth. As a caesarean birth can involve surgical and/or anesthetic complications, a VBAC is often safer for a woman and her baby than a repeat caesarean birth.1,2,3,5,6,7,8 There are also risks associated with a VBAC. Uterine rupture is one of the main risks.1,2,9

In considering whether to attempt a VBAC or to have a repeat caesarean birth, it is important for women to know the reason for their previous caesarean birth. The reason they needed to have a caesarean birth the last time they gave birth may not have changed, such as if they are HIV positive with a high viral load.1,2,9 Other times, the reason for a previous caesarean birth is non-recurring, such as dystocia, breech presentation, or an abnormal fetal-heart rate pattern and women could have a successful vaginal birth with their next pregnancy.1,2,10,11 It is also important for women to know the direction of the incision that was made in their uterus during their previous caesarean birth(s). Women who had a vertical uterine incision will not be able to have a VBAC as this poses a greater risk of complications such as uterine rupture.1,2,3

A woman’s decision to have a VBAC or a repeat caesarean birth is very individual. Women should be encouraged to carefully consider the benefits and the risks of a VBAC and a caesarean birth as well as their medical and obstetrical history to make an informed decision. Women need help and guidance as they make this decision.1,2,4,7,8,12,13,14,15,16,17 See the Interventions in Labour file to learn more about helping women make informed decisions for labour and birth.

VBAC success rate

Most women are good candidates for a trial of labour after a previous caesarean birth. In a large review, 74 percent of women who had a trial of labour after a previous caesarean birth had a successful vaginal birth.6 Similarly, in other large studies, the probability of a successful VBAC was between 60 percent and 80 percent.12,18 The probability was even higher for women who had a vaginal birth before their caesarean birth. 1,9In cases where a vaginal birth attempt is unsuccessful, a repeat caesarean section is performed.1,2

National and provincial statistics

From the late 1980s to the mid-1990s in North America, the repeat caesarean birth rate decreased and the VBAC birth rate increased. From 1979 to 1993, the VBAC rate rose more than tenfold from 3 percent to 33 percent.19 It is believed that this trend was largely due to increased evidence that VBAC is the safe choice in the absence of contraindications.1,19

Since the 1990s in North America and Canada, however, the rate of repeat caesarean births again increased and the VBAC rate declined1,4,18,20,21,22 There has been an increasing trend in caesarean births overall, with the largest contributor being repeat caesarean births.20

In Canada, repeat caesarean birth rates, defined as the number of caesarean births to women who have had a previous caesarean birth, have been as follows: 74.2 percent in 2001 – 2002; 82.0 percent in 2006 – 2007; and 81.8 percent in 2010 – 2011.23 Similar and slightly higher rates have been observed in Ontario.20,24,25

It is hypothesized that one reason for the increase again in repeat caesarean births may be a study published in Nova Scotia in 1996 stating that a caesarean birth is safer than a VBAC.18,26 Other studies, however, have not shown that this is the case for most women.

Obstetrical task groups are working to again reverse these rates.1,2,4,21,22 Uterine rupture is estimated to occur in only about 0.5 percent of all VBAC labours, meaning that one uterine rupture would be expected to occur for every 200 women who have a VBAC.10

Benefits of a VBAC

Benefits

There are several benefits of having a VBAC instead of a repeat caesarean birth. Many of these benefits are associated with having a vaginal birth over a caesarean birth.1,8

See the Caesarean Birth file for more information about risks associated with caesarean birth.

Maternal benefits

Some benefits of a VBAC for women include:1,2,3,4,5,10,27,28,29,30,31,32,33

  • No risk of surgical or anesthetic complications associated with a caesarean birth.
  • Reduced risk of blood loss and the need for a blood transfusion (shown in some studies).
  • Less pain in general.
  • The ability to move around sooner and less risk of developing venous thromboembolism.
  • A shorter recovery time.
  • Less risk of developing a fever and a postoperative wound infection.
  • Satisfaction with having a vaginal birth.
  • Increased likelihood of a successful vaginal birth in the future.

If a woman is planning to have more children, a VBAC can be especially beneficial for her as her risk of having an ectopic pregnancy and/or developing placenta previa, placental abruption, and placenta accreta increases with the number of caesarean births.2,9,10,16,30 If issues with the placenta occur this can cause serious antepartum and postpartum maternal bleeding and lead to issues for the fetus such as intrauterine growth restriction (IUGR), preterm birth, and/or a stillbirth.1,9,10,16

Neonatal benefits

Some benefits of a VBAC for a baby include:1,2,27,29

  • No risk of accidental surgical injury during a caesarean birth.
  • Less risk of requiring ventilation or other forms of neonatal resuscitation at the time of birth.
  • Increased potential for skin-to-skin contact with the baby at birth. Babies born by caesarean birth are more likely to be admitted to a nursery or a neonatal intensive care unit for breathing difficulties, which can affect the ability to place a baby skin-to-skin after birth.
  • Increased likelihood to be exclusively breastfed at three and six months.
  • Less risk of being born preterm if the estimated gestational age is incorrect. A preterm newborn can face many complications.

Risks of Having a VBAC

Uterine rupture

A VBAC is safe for most women, but it is not risk-free. One of the main risks is the possibility of uterine rupture (i.e., a tear which occurs along the scar line on the uterus from a previous caesarean birth.1,2,3,6,9 This is a rare event with an estimated risk below 0.5 percent.1

If it does occur, however, a woman will need to have an emergency caesarean birth. Uterine rupture increases the risk of maternal bleeding, the need for a hysterectomy, and/or fetal complications. In rare circumstances, maternal and/or perinatal death can occur following a uterine rupture, especially if actions are not taken immediately to protect the woman and baby.1,2,3,6,34

While uterine rupture is a serious event, maternal and perinatal outcomes are largely favourable.1

Repeat caesarean birth after a trial of labour

Another risk/challenge for women attempting a VBAC is that they will labour and then need to have a caesarean birth for reasons such as an abnormal fetal heart-rate pattern or the inability to progress through labour.1,2,10 This is estimated to occur for about one in four women who attempt a VBAC.10

See the Caesarean Birth file for more examples of why a caesarean birth following a trial of labour may be needed.

Factors which may increase risks of VBAC

The risks associated with a VBAC are often higher for women who:1,2,3,6,10,11,12,35,36,37,38

  • Have had caesarean birth less than 18 months prior as their uterus may have not had an adequate time to heal.
  • Have had three previous caesarean births. VBAC is still an option for women who have had more than one previous birth by caesarean, although the risk of complication is slightly higher.
  • Are older than 35 years of age.
  • Have a body mass index (BMI) greater than 30 kg/m2.
  • Undergo induction or augmentation of labour.
  • Are of Hispanic or African-American descent.

Having one of these above factors does not mean it is entirely unsafe to plan a VBAC. It just means that the risk of a uterine rupture is slightly higher but still low. It is estimated that even if a woman’s chances of having a VBAC are decreased, she still has a greater than 50 percent chance of having a vaginal birth.1,10,35

Contraindications to a VBAC

When a VBAC is not possible

A VBAC is not recommended for a woman who has contraindications to a vaginal birth in general. Such contraindications could be the reason a caesarean birth was performed previously.1,2,9

Other contraindications for a VBAC are as follows:1,2,3,6

  • A previous vertical incision or other type of uterine incision in the large body of their uterus, such as a classical incision or T incision as this increases a woman’s risk of uterine rupture.
  • A previous uterine rupture.

More information about contraindications for a vaginal birth is available in the Caesarean Birth file.

Obtaining the previous operative report

Before attempting a VBAC, a woman and her health care provider should review the type of uterine incision that was done for the previous caesarean birth and her potential risk of uterine rupture during a VBAC. It is not possible for women to know what type of uterine incision was made simply by the type of abdominal scar on their skin as the uterine incision is not always made in the same direction. Every effort should be made to obtain the previous caesarean birth operative report to determine the type of uterine incision that was made.

Other information in this record, such as the indication for the caesarean birth and the opinion of the previous surgeon for a future VBAC, may be helpful as well. Women can request this information from their primary health care provider in writing.

In situations where the incision is unknown, information concerning the circumstances of the previous birth can be helpful in determining the type of uterine incision. If the likelihood of a low horizontal incision is high, a VBAC may be appropriate. Unknown scars will be low horizontal uterine incisions 92 percent of the time.

However, if a woman’s history suggests the possibility of a vertical uterine incision, to reduce the risk of uterine rupture, a repeat caesarean birth is recommended.1,2,6

Factors which are not considered contraindications to a VBAC

Factors which are not considered contraindications to having a VBAC include:1,2

  • A single-layer closure technique used during the previous caesarean birth.
  • The degree of thickness of the uterine segment as seen on ultrasound.
  • Twin gestation.
  • Postdates pregnancy.
  • Macrosomia.
  • Diabetes mellitus/gestational diabetes.

External cephalic version (ECV) for a breech presentation is also not contraindicated for women who have had a previous caesarean birth.2

Close Monitoring during a VBAC

Birth location

The safest place for a VBAC is a hospital equipped with an operating room and staff to perform surgery if required. Suspected uterine rupture requires urgent attention to decrease maternal and perinatal/neonatal risks.2,3

If a woman wants to have a home birth, she should discuss plans for emergency transport to a hospital with her midwife in advance.1,10 This should include planning for transport during rush hour if the woman lives in a larger city.

Home birth is not recommended for a VBAC by the SOGC.1,3

Maternal and fetal monitoring

During a VBAC, when a woman is in active labour, her contractions and the fetal heart rate should ideally be monitored continuously.1,2,39 One of the most common signs of uterine rupture is an abnormal fetal-heart rate pattern.1,2 More information on continuous fetal heart rate monitoring can be found in the Interventions in Labour file.

Other signs of possible uterine rupture that health care providers will look for during a VBAC include:1,2

  • The cessation of contractions.
  • The inability to locate the presenting part of the fetus on vaginal examination.
  • Excessive vaginal bleeding.
  • The presence of blood in a woman’s urine.
  • Maternal cardiovascular instability such as low blood pressure and tachycardia.
  • Abdominal pain that is different from the contraction pain that the woman is experiencing. However, this can often be difficult to determine.

A woman’s labour progress, based on her cervical dilation, will be checked regularly, which is typically every four hours or as the need arises as some research suggests that prolonged labour or labour dystocia can increase the risk of uterine rupture.1,2

Labour support and pain management during a VBAC

Women having a VBAC need a strong support system prior to, during, and after labour and birth. Anxiety can increase release of stress hormones called catecholamines, which can inhibit the release of oxytocin in a woman’s body delaying the progress of labour. A labour support person can be especially helpful for women attempting a VBAC.2,11

Pain-management options are not restricted for women having a VBAC.1,2

Induction and Augmentation of Labour during a VBAC

Induction and augmentation possibilities during a VBAC

Spontaneous labour is preferred over induced labour for VBAC to reduce the risk of uterine rupture.

To prevent a repeat caesarean birth, however, induction and/or augmentation of labour for woman having a VBAC is sometimes indicated.1,2 For a full description of methods of induction and augmentation of labour, see the Interventions in Labour file.

Some methods are preferred over others for women undergoing a VBAC.1,2,3,40 It is important that women learn about these methods when planning a VBAC. As with all inductions, the reason for it needs to be compelling and informed consent must be obtained.2,40

Acceptable methods of induction and augmentation of labour during a VBAC

Foley catheter

To ripen a women’s cervix when it is not yet ready for labour, a health care provider may insert a Foley catheter  into the lower part of her uterus through her cervical opening.40 This method of cervical ripening is considered the safest method for woman having a VBAC as it does not involve the use of medications. It is not, however, effective for all women.2

Oxytocin

Oxytocin is a hormone responsible for causing uterine contractions. It is available in a synthetic form and can be used to induce as well as augment labour. It can be used for women having a VBAC. There is a risk of uterine rupture when it is used, but the risk is not as great as when prostaglandins are used.1,2,40

Amniotomy

An amniotomy may be performed for women with a favourable cervix having a VBAC. This will be done with the administration of oxytocin.1,2,40

Contraindicated methods of induction and augmentation of labour during a VBAC

Prostaglandins

Prostaglandins are a type of hormone, which can soften/ripen a woman’s cervix for vaginal birth.40 Prostaglandin medications can include a medicated insert called Cervidil, a gel-like substance, and an oral tablet. These are not safe to use for women having a VBAC as they have been shown to increase the risk of uterine rupture.1,2,40

Uncertain methods of induction and augmentation of labour during a VBAC

Natural methods

There is little evidence regarding the safety and effectiveness of herbs, homeopathics, acupuncture, or other proposed, natural methods of induction and/or augmentation of labour for women planning VBAC. Women should discuss methods they may be considering with their health care provider before using them.1

Membrane sweep

A membrane sweep is not a true method of induction, but it is sometimes done by a health care provider at or around the expected due date to try to stimulate labour.40 A 2009 study involving 108 women attempting a VBAC, however, found that a membrane sweep was ineffective in stimulating labour.41

Postpartum Care

Postpartum care after a VBAC or a repeat caesarean birth

Close postpartum observation

Following a VBAC or a repeat caesarean birth, women are still at risk of uterine rupture and hemorrhage. Signs of this, such as an increase in vaginal bleeding, a boggy uterus, and unstable vital signs, will be monitored closely in the postpartum period.1,2

Discussion about future births in the postpartum period

In the postpartum period, preferably before discharge, a woman and her health care provider, or the surgeon if applicable, should discuss the birth and her likelihood for a VBAC in the future.1,2,11

Women who have a repeat caesarean birth should try to obtain:1,2,11

  • A written copy or a summary of the operative report indicating the type of uterine incision.
  • The surgeon’s opinion of the best options for future births.
  • The preferred time interval before the next birth if desired.

Referrals

When to refer

Women and/or their support people may need to be referred for additional support if they:

  • Are overly anxious or fearful about having a VBAC or a repeat caesarean birth.
  • Need more information about how to prepare for a VBAC, what to expect during a VBAC, and/or how to care for themselves during the postpartum period following a VBAC.

Where to refer

Women and/or their support people who require more information and/or support in regards to a VBAC can be referred to the following sources:

  • Their health care provider (obstetrician, family physician, Nurse Practitioner, or midwife).
  • Prenatal education classes (if not already enrolled).
  • Support groups.

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Resources & Links



Please note this is not an exhaustive list of available resources, nor should any of these resources be used in place of seeking professional advice. The resources cited throughout this resource are not necessarily endorsed by the Best Start Resource Centre or the Government of Ontario. When in doubt, professionals should contact the organization responsible for issuing a specific recommendation/practice guideline.

Professional Guidelines

Reports/Publications

Websites

Client Resources and Handouts

Books

  • Vadeboncoeur, H. (2011). Birthing normally after a cesarean or two. Fresh Heart Publishing.

Apps

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References

  1. Association of Ontario Midwives. (2004). Clinical practice guidelines no. 14: Vaginal birth after previous low-segment caesarean section. Toronto, ON: Author. Retrieved from http://www.ontariomidwives.ca/images/uploads/guidelines/No14CPG_VBAC_Final_November_2011.pdf
  2. Martel, M. J., & MacKinnon, C. J. (2005). Guidelines for vaginal birth after previous caesarean birth.Journal of Obstetrics and Gynaecology Canada,27(2), 164-188. Retrieved from http://www.jogc.com/
  3. Society of Obstetricians and Gynaecologists of Canada. (2009). Vaginal birth after caesarean section. Ottawa, ON: Author. Retrieved from http://pregnancy.sogc.org/labour-and-childbirth/vaginal-birth-after-caesarean-section/
  4. King, T. L. (2011). Can a vaginal birth after cesarean delivery be a normal labor and birth? Lessons from midwifery applied to trial of labor after a previous cesarean delivery. Clinics in Perinatology, 38(2), 247-263. doi: 10.1016/j.clp.2011.03.003
  5. Catling‐Paull, C., Johnston, R., Ryan, C., Foureur, M. J., & Homer, C. S. (2011). Non‐clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review. Journal of Advanced Nursing, 67(8), 1662-1676. doi: 10.1111/j.1365-2648.2011.05662.x
  6. Guise, J. M., Denman, M. A., Emeis, C., Marshall, N., Walker, M., Fu, R., . . . McDonagh, M. (2010). Vaginal birth after cesarean: New insights on maternal and neonatal outcomes. Obstetrics & Gynecology, 115(6), 1267-1278. doi: 10.1097/AOG.0b013e3181df925f
  7. Lundgren, I., Begley, C., Gross, M. M., & Bondas, T. (2012). ‘Groping through the fog’: A metasynthesis of women’s experiences on VBAC (Vaginal birth after Caesarean section). BMC Pregnancy and Childbirth, 12(85), 1-11. doi: 10.1186/1471-2393-12-85
  8. Society of Obstetricians and Gynaecologists of Canada. (2008). Joint policy statement on normal childbirth. Journal of Obstetrics and Gynaecology Canada, 30(12), 1163-1165. Retrieved from http://www.jogc.com/
  9. Daltveit, A. K., TollÄnes, M. C., PihlstrÞm, H., & Irgens, L. M. (2008). Cesarean delivery and subsequent pregnancies. Obstetrics & Gynecology, 111(6), 1327-1334. doi: 10.1097/AOG.0b013e3181744110
  10. Association of Ontario Midwives. (2012). Thinking about VBAC. Toronto, ON: Author. Retrieved from http://www.aom.on.ca/files/Health_Care_Professionals/Clinical_Practice_Guidelines/vbac011013.pdf
  11. Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Chapter 19: Labour and birth at risks. In C. Sams & L. Keenan-Lindsay (Eds.), Maternal child nursing care in Canada (pp. 519-520). Toronto, ON: Elsevier Canada.
  12. Grobman, W. A. (2010). Rates and prediction of successful vaginal birth after cesarean. Seminars in Perinatology, 34(4), 244-248. doi: 10.1053/j.semperi.2010.03.003
  13. Health Canada. (2000). Chapter 5: Care during labour and birth. Family-centred maternity and newborn care: National guidelines (pp.5-49). Ottawa, ON: Author.
  14. Horey, D., Kealy, M., Davey, M. A., Small, R., & Crowther, C. A. (2013). Interventions for supporting pregnant women’s decision‐making about mode of birth after a caesarean. Cochrane Database of Systematic Reviews, 7(CD010041), 1-54. doi: 10.1002/14651858.CD010041.pub2
  15. Kaimal, A. J., & Kuppermann, M. (2010). Understanding risk, patient and provider preferences, and obstetrical decision making: Approach to delivery after caesarean. Seminars in Perinatology, 34(5), 331-336. doi: 10.1053/j.semperi.2010.05.006
  16. Kennare, R., Tucker, G., Heard, A., & Chan, A. (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
  17. Moffat, M. A., Bell, J. S., Porter, M. A., Lawton, S., Hundley, V., Danielian, P., & Bhattacharya, S. (2007). Decision making about mode of delivery among pregnant women who have previously had a caesarean section: A qualitative study. BJOG: An International Journal of Obstetrics & Gynaecology, 114(1), 86-93. doi: 10.1111/j.1471-0528.2006.01154.x
  18. Kelly, S., Sprague, A., Fell, D. B., Murphy, P., Aelicks, N., Guo, Y., . . . Walker, M. (2013). Examining caesarean section rates in Canada using the Robson classification system. Journal of Obstetrics and Gynaecology Canada, 35(3), 206-214. Retrieved from http://www.jogc.com/
  19. Millar, W. J., Nair, C., & Wadhera, S. (1996). Declining cesarean section rates: A continuing trend? Health reports, 8(1), 17-24. Retrieved from http://www.statcan.gc.ca/pub/82-003-x/1996001/article/2822-eng.pdf
  20. Better Outcomes Registry & Network (BORN) Ontario. (2012). Reporting using the Robson Cesarean section classification: BORN provincial rounds. Ottawa, ON: Author. Retrieved from http://www.bornontario.ca/assets/documents/provincialrounds/Robson%20Cesarean%20Section%20Classification%20-%20November%202012.pdf
  21. Gibbons, L., BelizĂĄn, J. M., Lauer, J. A., BetrĂĄn, A. P., Merialdi, M., & Althabe, F. (2010). The global numbers and costs of additionally needed and unnecessary Caesarean sections performed per year: Overuse as a barrier to universal coverage. Geneva, CH: World Health Organization. Retrieved from http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf
  22. Rossignol, M., Moutquin, J. M., Bougrassa, F., BĂ©dard, M. J., Chaillet, N., Charest, C., . . . Senikas, V. (2013). Preventable obstetrical interventions: How many caesarean sections can be prevented in Canada. Journal of Obstetrics and Gynaecology Canada, 35(5), 434-443. Retrieved from http://www.jogc.com/
  23. Public Health Agency of Canada. (2013). Perinatal health indicators for Canada for 2013: A report from the Canadian perinatal surveillance system. Ottawa, ON: Author. Retrieved from http://sogc.org/wp-content/uploads/2014/05/REVISEDPerinatal_Health_Indicators_for_Canada_2013.pdf
  24. Canadian Institute of Health Information (CIHI). (2013). Highlights of 2011–2012 selected indicators describing the birthing process in Canada. Retrieved from https://secure.cihi.ca/free_products/Childbirth_Highlights_2011-12_EN.pdf
  25. Canadian Institute of Health Information (CIHI). (2015). Quick stats: Childbirth indicators by place of residence [Database]. Retrieved from http://apps.cihi.ca/mstrapp/asp/Main.aspx?Server=apmstrextprd_i&project=Quick+Stats&uid=pce_pub_en&pwd=&evt=2048001&visualizationMode=0&documentID=029DB170438205AEBCC75B8673CCE822
  26. McMahon, M. J., Luther, E. R., Bowes Jr, W. A., & Olshan, A. F. (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
  27. Chalmers, B., Kaczorowski, J., Darling, E., Heaman, M., Fell, D. B., O’Brien, B., & Lee, L. (2010). Cesarean and vaginal birth in Canadian women: A comparison of experiences. Birth, 37(1), 44-49. doi: 10.1111/j.1523-536X.2009.00377.x
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Health Before Pregnancy

Health Before Pregnancy

Routine Prenatal Care

Routine Prenatal Care

Physical Changes

Physical Changes

Healthy Eating & Weight Gain

Healthy Eating & Weight Gain

Active Living

Active Living

Alcohol

Alcohol

Smoking

Smoking

Medications & Drugs

Medications & Drugs

Safety During Pregnancy

Safety During Pregnancy

Abuse

Abuse

Mental Health

Mental Health

Pregnancy & Infant Loss

Pregnancy & Infant Loss

Preterm Labour

Preterm Labour

Labour Progress

Labour Progress

Labour Support

Labour Support

Interventions in Labour

Interventions in Labour

Pain Medications in Labour

Pain Medications in Labour

Caesarean Birth

Caesarean Birth

Vaginal Birth After Caesarean

Vaginal Birth After Caesarean

Breech Birth

Breech Birth

Newborn Care

Newborn Care

Newborn Safety

Newborn Safety

Breastfeeding

Breastfeeding

Recovery After Birth

Recovery After Birth

Transition to Parenthood

Transition to Parenthood