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50 Deaconess 40 Holy Family UPDATED: AUGUST 2014 30 Valley 20 60 10 50 Deaconess 0 40 Holy Family 30 Valley Hospital Maternity Guide 2009 2010 2011 2012 2013 20 60 10 Sacred Heart 50 0 Deaconess 2009 40 Spokane & Coeur d’Alene Hospitals 30 25 20 PROCEDURE RATES 10 Total C-Section Rates 5 All Births 2009 2010 Deaconess Kootenai 2011 Holy Family 2012 2013 Sacred Heart 15Deaconess Valley Kootenai 2012 2013 Holy Family Sacred Heart Valley 20 16.7% 2012 Source: WA State Department of Health. Kootenai reported its own rates. Holy Family Valley Sacred Heartknowing a hospital’s Beyond Deaconess cesarean and other procedure Holy Family rates, it is also important to know Valley your care provider’s individual rates which are a larger determinof care you will receive. Deaconess 2010 2011 201322.0% 2012 18.6% 16.0% Holy Family Valley 2012 Total Deliveries Kootenai 9.4% 2010 2011 2012 2013 Source: WA State Health Care Authority. Kootenai rates not available. 20 35 3.5 Deaconess ing factor Sacred Heart in predicting the kind 25 Sacred Heart 5 2009 Deaconess 20 Holy Family 15 Valley 35 10 30 5 2009 25 26.0% 25.0% 25 2011 2011 30 10 Kootenai 31.1% 30.8% 30 2010 2010 NTSV C-Section Rates 35 15 Sacred Heart Holy Family 30 Valley 20 30 10 250 2009 2010 2011 2012 2013 20 Primary C-Sections Among Low Risk, First Time Mothers 15 Sacred Heart Sacred Heart: . . . . . . . . . 2,863 Deaconess: . . . . . . . . . . 1,777 Kootenai: . . . . . . . . . . . . 1,642 Holy Family Valley Holy Family: . . . . . . . . . . 1,245 Valley: . . . . . . . . . . . . . . . . 623 Sacred Heart Deaconess Kootenai VBAC Rates 3.0 15 Valley 30 Sacred Total: Heart . . . . . . . . . . . . . . 8,150 2.5 Vaginal Birth After Cesarean Before 39 Weeks (Data for 2013) 25 Holy Family 2.0 Deaconess Kootenai 1.5 60 1.0 Holy Family Early Elective2011 Delivery 2012 Rates 2010 Sacred Heart Holy Family Sacred Heart Valley 50 0.5 0.0 40 Goal: 5% or less. WA State Average (2013): 1.5% Valley Sacred Heart Valley Deaconess 20 3.5 3.0 15 3.2% Deaconess 2010 2.5 47.7% Vaginal Births Deaconess 20 17.5% 1.0 3.5 0.5 3.0 0.0 2.5 2010 2011 2012 1.5 2013 0.8% Deaconess 0.9% 0.0% Holy Family Sacred Heart Valley 2.0 1.5 Valley Sacred Heart Holy Family Deaconess Source: WA State Department of Health. Kootenai reported its own rates. 1.0 Sacred Heart 0.5 25 VBAC 6.8% 65.2% Source: Washington State Hospital Association. Kootenai rates not available. Percent of vaginal births among women whose pregnancies were at term, had a single fetus with vertex (head-down) presentation, and who had one prior c-section. Source: 30 WA State Health Care Authority. Kootenai does not allow VBACs. C-Sections 28% Sacred Heart Holy Family 2.0 2009 2012 Valley 34.3% 26.5% 0 2011 Holy Family 30 10 Deaconess Deaconess 0.0 Holy Family 20 FACILITIES Valley 15 10 Deaconess Kootenai Holy Family Sacred Heart Valley Day Bed Day Bed Day Bed Day Bed Fold-Out Bed Room &Kootenai Meals No Room Room** Room & Meals Yes In Process In Process No DF/GF/NF V/GF/LC/LS V/GF/LC/LS DF/GF/NF NICU (Level IV) Nursery (Level I) 5 2009 2010 2012 Accommodations for2011 a Guest 2013 35 Accommodations for NICU Parents Sacred Heart 30 Deaconess Baby-Friendly Designated Facility No Holy Family 25 20Meal Valley Options 15 2010 NICU/Nursery DF/GF/NF 2011 2012 Parking NICU (Level III) Pay Garage 3.5 3.0Patient Valley Rooms LDR >Sacred PP Heart 2.5 Photography/Video Free Lot Pay/Valet M-F Free Lot LDR > PP Triage > LDRP Triage > LDR > PP LDRP Deaconess Yes* Yes*Yes*Yes* Yes* 1.5 0.5Rooming-In Free Lot Holy Family 2.0 1.0 Nursery (Level II) Nursery (Level II) with Baby Routine RoutineRoutineRoutine Routine 0.0 Water Birth No NoNoNo No WiFi Yes YesYesYes Yes *Photography/Video is allowed, but not during procedures **Or at Ronald McDonald House (free) or the Madison Inn (discounted “medical rates”) Source: All hospitals reported their own data and policies BLOOM SPOKANE HOSPITAL MATERNITY GUIDE 2014 1 CARE PROVIDERS & STAFF Deaconess Kootenai Holy Family Sacred Heart Valley Anesthesiology – 24-hour Coverage Yes YesYesYes Yes Family Practice Docs (attending births) 15+4 1 14 0 Lactation Consultants (availability) Midwives (attending births) Nurse-to-Patient Ratio (active labor) 7 Days/Week 7 Days/Week 6 Days/Week 6 Days/Week M–Sat. 9 402 2 1:1 1:1 1:11:1-2 1:1 Obstetricians On Site On Call On Site 24/7 On Site 24/7 On Call Pediatricians On Site On Site Available 24/7 Available 24/7 On Site CHAS Deaconess Hospital Maternal-Fetal Medicine Health Care for Women Henneberg & Kim OBGYN Kootenai Clinic OBGYN Associates for Women’s Health North Spokane Women’s Health Group Health Northwest OBGYN Northwest Midwives OBGYN Associates of OBGYN Associates of Spokane Rockwood OBGYN Rockwood Midwifery Spokane OBGYN & Midwifery Kootenai Clinic Family Medicine Coeur d’Alene Private Practices & Clinics Attending Births Valley OBGYN Spokane Providence Sacred Heart Maternity Clinic Spokane OBGYN PRENATAL & POSTPARTUM SUPPORT Breastfeeding Classes Deaconess Kootenai Holy Family Sacred Heart Valley Coming Soon YesYesYes Yes Childbirth Classes* Yes YesYesYes Yes Lactation Assistance (outpatient clinic) Yes YesYesYes Yes Natural Childbirth Classes Coming Soon No Newborn Care Classes Coming Soon Yes Postpartum Support Group(s) Coming Soon No Yes Kootenai Holy Family Yes Yes No Newborn/First Aid/CPR Newborn/First Aid/CPRNo Yes Yes *Childbirth Classes may also conatin information about natural childbirth and breastfeeding. LABOR AIDS Deaconess Sacred Heart Valley Birthing Balls & Peanut Balls Yes YesYesYes Yes Birthing Chairs/Stools No NoYesNo No Continuous Doula Care Supported Yes Squatting Bars Yes YesYesYes Yes Wireless/Waterproof EFM Yes YesYesNo Yes Tubs/Showers Both (Jetted Tubs) Yes Both In Process In Process Both (Jetted Tubs) Both (Jetted Tubs) Yes Showers Source: All hospitals reported their own data and policies 2 BLOOM SPOKANE HOSPITAL MATERNITY GUIDE 2014 LOW RISK AND UNMEDICATED PATIENTS The following options are available if your pregnancy was low risk, you and your baby are doing well in labor, and you remain unmedicated. Deaconess Kootenai Holy Family Sacred Heart Valley Birthing Position Choices H H H H H Delayed Cord Clamping H H H H H Eating & Drinking in Labor Yes Yes Clear Liquids Clear Liquids Clear Liquids Fetal Monitoring Intermittent EFM† Intermittent EFM† Intermittent EFM† Intermittent EFM Saline Lock Routine Skin-to-Skin Care Routine RoutineRoutineRoutine Routine Water Immersion Restrictions in Labor † Intermittent EFM† Routine Routine RoutineRoutine None NoneNoneNone None H = Shared Patient/Provider Decision (see page 4) Wireless, waterproof EFM available (patients can leave bed or be in tub) HIGH RISK AND/OR MEDICATED PATIENTS The following options are available if you or your baby has an increased risk of health problems or you are experiencing a high risk pregnancy. This could include pre-term labor, preeclampsia, placenta issues, diabetes, fetal issues, etc. The following options also apply if at any point during your labor you consent to medication (induction, pitocin, epidural, etc.) or there are indications that you or baby are not coping well. Deaconess Kootenai Holy Family Sacred Heart Valley Birthing Position Choices H H H H H Breech Birth Allowed No NoNoNo No Delayed Cord Clamping H H H H H Eating & Drinking in Labor H Yes Clear Liquids Clear Liquids Clear Liquids Fetal Monitoring Continuous EFM† Continuous EFM† Continuous EFM† Continuous EFM Routine IV Fluids No HRoutine Skin-to-Skin Care (if stable at birth) Routine RoutineRoutineRoutine Routine Vaginal Delivery of Twins Yes / H Water Immersion Restrictions in Labor † H Routine Continuous EFM† Yes Yes / HYes Yes NoneNone H HNone H = Shared Patient/Provider Decision (see page 4) Wireless, waterproof EFM available (patients can leave bed or be in tub) C-SECTION OPTIONS Deaconess Kootenai Holy Family Sacred Heart Valley Delayed Cord Clamping --YesHNo No Doulas in OR H Newborn Care in OR (if stable at birth) Yes YesYesYes Yes Photography/Video in OR Photos Only* H Skin-to-Skin in OR (Operating Room) *Photography/Video of mom and baby is allowed, but not procedures Source: All hospitals reported their own data and policies Yes** -- 1 Support Person Photos Only* Photos Only* 1 Support Person Photos Only* YesYesNo Yes **With permission from the anesthesia provider BLOOM SPOKANE HOSPITAL MATERNITY GUIDE 2014 Yes** H = Shared Patient/Provider Decision (see page 4) 3 DEFINITIONS & EVIDENCE FOR MATERNITY CARE PRACTICES Baby-Friendy Designated Facility The Baby-Friendly Hospital Initiative (BFHI) is a global program that was launched by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in 1991 to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/baby bonding. The BFHI assists hospitals in giving all mothers the information, confidence, and skills necessary to successfully initiate and continue breastfeeding their babies or feeding formula safely, and gives special recognition to hospitals that have done so.1 Birthing Positions Evidence Based Birth says, “The best quality medical evidence shows that women should push in whatever position is comfortable for them. It is not necessary to be continuously upright or continuously lying down during the pushing phase. More evidence is needed to evaluate pushing positions in women with traditional (non-walking) epidurals.”2 Speak with your care provider to find out if your birthing positions will be limited or unrestricted. Breech Birth A breech birth is one in which the baby is born buttocks or feet first as opposed to the normal headfirst presentation. Though vaginal birth is possible for the breech baby, certain fetal and maternal factors influence the safety of vaginal breech birth. The majority of breech babies born in the United States are delivered by Cesarean section as most obstetricians no longer have the required skill set and most hospital policies do not permit vaginal breech birth. C-Section Rates Total C-Section Rate: The cesarean section rate, or total number of cesareans per 100 births, rose dramatically for 12 years in the United States—approximately 60 percent from 1996 to 2009. The Specifications Manual for Joint Commission National Quality Measures (v2011A) cites research which concludes that “Hospitals with CS rates at 15-20% have infant outcomes that are just as good and have better maternal outcomes.”3 NTSV C-Section Rate: This measure focuses on primary cesareans among low risk, first time mothers: nulliparous women with a term, singleton baby in a vertex (head down) position delivered by cesarean section. Term is defined as gestational age of at least 37 completed weeks. “Primary cesarean deliveries account for 50% of the increasing total cesarean delivery rate. Given its effect on subsequent pregnancies, an understanding of the drivers behind the increase in primary cesarean delivery rates and renewed efforts to reduce 4 them may have a substantial effect on maternal health. The top five contributors to the primary cesarean delivery rate are nonreassuring fetal status, arrest of labor, multiple gestation, preeclampsia, and macrosomia. All five contributors are either subjective or depend on management style. Thus, the decision the patient makes as to whom she will see for her prenatal care and which physician will be on call for her delivery may be major determinants as to whether she will end up with a cesarean delivery or a vaginal birth.”4 Continuous Doula Care When a laboring woman is continuously supported by a trained doula (the doula never leaves her side), both she and her baby experience better outcomes. Her partner is also likely to feel more positive about the birth. In the past, some hospitals have limited patients to one support person in triage and during procedures such as epidural placement. In these instances, the mother had to choose between her loved one and her skilled support person. The benefits of hiring a doula may be diminished when continuous care is not supported. At this point, all our local hospitals understand the importance of Continuous Doula Care and allow for this or are in process of providing families with unlimited doula support.5 Delayed Cord Clamping According to Evidence Based Birth, “Delayed Cord Clamping (DCC) promotes a healthy neonatal cardiopulmonary transition, prevents iron deficiency at a critical time in brain development, provides the newborn with a rich supply of stem cells, and helps sick neonates achieve better outcomes—all with little apparent risk to mother or baby. The evidence of benefit from DCC is so compelling that the burden of proof must now lie with those who wish to continue the practice of immediate clamping, rather than with those who prefer—as nature intended—to wait.”6 H Shared Patient/Provider Decision For some options there are no specific hospital policies and a mutual decision can be made between the patient and care provider. Have a conversation with your care provider about what is possible. Prior to giving birth, some families decide to transfer to a different care provider that is more comfortable supporting desired options for labor and birth. Informed Decision Making Childbirth Connection provides the following guidance on Informed Decision Making: “When pregnant, giving birth, and in the postpartum period, it is your responsibility to make informed decisions for yourself and on behalf of your baby. It is your legal right to give ‘informed consent’ or make an ‘informed refusal’ of any care that you might undergo. Whenever a medical procedure, drug, test, or other treatment is offered to you, your doctor, midwife, or nurse is responsible for explaining: • why this type of care is being offered • what it would involve • the harms and benefits that are associated with this type of care • alternatives to this care, and their respective harms and benefits, including the possibility of doing nothing at the present time (‘watchful waiting’).”18 Early Elective Delivery Rates This measure looks at the percent of deliveries performed between 37 and 39 weeks gestation that were not medically necessary. Babies born prior to 39 weeks gestation face higher rates of complications and are more likely to spend time in the neonatal intensive care unit. Washington hospitals have decreased the statewide average from 15.3% in the third quarter of 2010 to 1.5% in the fourth quarter of 2013. Eating & Drinking in Labor A 2013 Cochrane Review found, “Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labor for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women.”8 BLOOM SPOKANE HOSPITAL MATERNITY GUIDE 2014 DEFINITIONS & EVIDENCE FOR MATERNITY CARE PRACTICES Fetal Monitoring offer sustained life support, advanced imaging, and a range of surgical procedures. The following definitions and evidence are from the Evidence Based Birth article, Evidence-Based Fetal Monitoring. Level IV: Regional NICU The highest level of neonatal care provided occurs at regional NICUs. They are required to have pediatric surgical sub-specialists in addition to the care required for Level I, II, and III units. Continuous EFM: Continuous Electronic Fetal Monitoring (EFM) during labor is not supported by evidence. It is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous EFM is associated with an increase in cesarean sections and instrumental vaginal births.9 BloomSpokane.org EvidenceBasedBirth.com ImprovingBirth.org Patient Rooms Triage Some hospitals use triage rooms for initial labor assessment and testing when patients first arrive. After assessment, you will either be admitted to the hospital or discharged with instructions on when to call or return. Some triage areas are small and limit the number of support people allowed to accompany patients. Intermittent EFM: There is no evidence that intermittent monitoring with the electronic fetal monitor is any better than continuous electronic monitoring. 9 Intermittent Auscultation: Based on the evidence, the best option for most women and babies is intermittent auscultation. With this method, the care provider listens to the baby’s heart rate for about 60 seconds using a fetal stethoscope (fetoscope or Pinard) or a hand-held Doppler ultrasound device.9 Labor, Delivery, and Recovery (LDR) In many hospitals, especially larger ones, LDR rooms are where you will give birth and do your immediate postpartum recovery. LDR rooms are equipped to handle vaginal births, including those with epidurals and other pain medications. Following birth you will move to a postpartum room with your baby. Midwives According to Childbirth Connection, “Care by certified nurse-midwives (CNMs) is generally associated with a lower likelihood of using various labor and birth interventions than maternity care with doctors. Midwives are well-suited to care for healthy women who expect to have a normal birth. Many give priority to providing good information to women, involving women in decision-making, and providing flexible and responsive care.”10 Labor, Delivery, Recovery, Postpartum (LDRP) LDRP rooms allow you to remain in one place for your entire stay at the hospital, from admittance in labor to discharge. You will give birth in this room and your baby will stay with you until you are ready to go home. As with the LDR, the LDRP is equipped to handle only vaginal births. Postpartum (PP) After giving birth, the rest of your stay in the hospital will be spent in a Postpartum Room. In most hospitals, rooming-in with baby is routine both day and night. You and your newborn will receive care from nurses as well as breastfeeding support. Lactation Consultant (IBCLC) During your hospital stay, you will receive breastfeeding assistance and support from an International Board Certified Lactation Consultant. They work collaboratively with primary care providers and nurses to assure appropriate clinical/practical management of breastfeeding and lactation in order to protect, promote, and support breastfeeding. Routine IV Fluids VBACFacts.com ChildbirthConnection.org TheUnnecesarean.com Evidence-Based Care Evidence-based maternity care uses the best available research on the safety and effectiveness of specific practices to help guide maternity care decisions and to facilitate optimal outcomes in mothers and newborns, while also taking into account an individual woman’s values.19 Patient-Centered Care Patient-centered care supports active involvement of patients and their families in decision-making about individual options for treatment. The Institute of Medicine defines patient-centered care as, “Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”20 According to Evidence Based Birth, “Among women who have unrestricted access to oral fluids, IV hydration during labor offers only one advantage— it may reduce the incidence of nausea/vomiting. It does not have any other benefits. It does not shorten the length of labor. The risks are that IV hydration during labor may lead to an artificially high drop in the newborn’s weight, which can adversely affect breastfeeding. The risks related to post-partum edema and engorgement are unknown.”11 Neonatal Intensive Care Unit (NICU) Level I: Well Newborn Care These nurseries care for healthy, full-term babies. They are able to stabilize babies born near term to get them ready to transfer to facilities that offer special care. Level II: Specialty Newborn Care Special care nurseries can care for babies born at greater than 32 weeks gestation or who are moderately ill with problems that are expected to resolve rapidly without urgent or sub-specialty care. Saline Lock The saline lock is a clamped off IV that is often used for low-risk mothers in labor. It allows immediate access to the vein in the event of a complication, to deliver IV pain medications like Nubain, Fentanyl, etc., should the mother request epidural anesthesia, require a cesarean section (c-section) or have a postpartum hemorrhage. Level III: Neonatal Intensive Care Level III NICUs care for the sickest babies and are required to have pediatric surgeons. These nurseries care for babies born greater than 28 weeks. They BLOOM SPOKANE HOSPITAL MATERNITY GUIDE 2014 Online Resources 5 DEFINITIONS & EVIDENCE FOR MATERNITY CARE PRACTICES Evidence Based Birth says, “There is little-to-no evidence for the use of a saline lock during an un-medicated labor. However, there are risks and benefits to having the saline lock. The ultimate decision for whether or not to have a saline lock should come from you.”12 Review the risks and benefits of a saline lock at evidencebasedbirth.com. Skin-to-Skin Care Evidence Based Birth says, “Early skin-to-skin care (also called kangaroo care) is a natural process that involves placing a naked newborn chest down on the mother’s bare chest and covering the infant with blankets to keep it dry and warm. Ideally, skin-toskin care starts immediately after birth or shortly after birth, with the baby remaining on the mom’s chest until at least the end of the first breastfeeding session. The benefits of skin-to-skin care are so clear that the World Health Organization recommends ALL newborns receive skin-to-skin care, no matter the baby’s weight, gestational age, birth setting, or clinical condition. (WHO, 2003)”13 Skin-to-Skin Care After a Cesarean “Research to-date demonstrates that ‘very early’ skin-to-skin care after a Cesarean is safe and beneficial. Evidence has shown that it is possible—and best practice—for moms and babies to stay together after a Cesarean. Mothers who want to do very early skin-to-skin care and interact with their babies after a C-section should talk with their providers about this. Moms should also talk with their anesthesiologists to make sure that they do not receive sedative drugs unless medically necessary, as these drugs may make some women incapable of early interaction with their newborns.”14 planned vaginal delivery. No data support planned cesarean for birthweight discordance alone. Local Hospitals Obstetricians need to be prepared for, and skilled in, breech extraction of the second twin. Individualized patient counseling regarding mode of delivery is important when offering a vaginal trial of labor to women with a twin gestation.”16 Deaconess Medical Center Vaginal Birth After Cesarean (VBAC) Per the American College of Obstetricians and Gynecologists, VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans. Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC.17 800 West Fifth Avenue Spokane, WA 99204 Phone: (509) 473-7241 Kootenai Health 2003 Kootenai Health Way Coeur d’Alene, ID 83814 Phone: (208) 666-2123 Providence Holy Family 5633 N Lidgerwood St Spokane, WA 99208 Phone: (509) 482-BABY More Information on VBAC: vbacfacts.com Providence Sacred Heart Medical Center References 101 West 8th Ave. Spokane, WA 99204 Phone: (509) 474-2400 1. Baby-Friendly USA, Inc. http://www.babyfriendlyusa.org/ 2. Dekker R, “What is the Evidence for Pushing Positions?,” http://evidencebasedbirth.com/what-is-the-evidence-for-pushing-positions/ 3. Cesareanrates.com. http://www.cesareanrates.com/about/ 4. W. Lawrence Warner, MD, “Arriving at the Appropriate Cesarean Delivery Rate,” ACOG District VIII Gazette (July 2013). 5. Dekker R, “The Evidence for Doulas,” http://evidencebasedbirth.com/the-evidence-for-doulas/ Valley Hospital 12606 E Mission Ave Spokane Valley, WA 99216 Phone: (509) 473-5475 6. Sloan M, “Common Objections to Delayed Cord Clamping – What’s The Evidence Say?,” Science & Sensibility, http://www.scienceandsensibility. org/?p=5730 7. Washington State Hospital Association, www.wsha.org 8. Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003930. DOI: 10.1002/14651858.CD003930.pub3. 9. Dekker R, “Evidence-Based Fetal Monitoring,” http://evidencebasedbirth.com/ evidence-based-fetal-monitoring/ 10. Childbirth Connection, http://www.childbirthconnection.org/article.asp?ck=10163&ClickedLink=247&area=27 11. Dekker R, “Are IV Fluids Necessary during Labor?,” http://evidencebasedbirth. com/are-iv-fluids-necessary-during-labor/ 12. Dekker R, “Evidence for the Saline Lock during Labor,” http://evidencebasedbirth.com/the-saline-lock-during-labor/ 13. Dekker R, “The Evidence for Skin-to-Skin Care after a Cesarean,” http:// evidencebasedbirth.com/the-evidence-for-skin-to-skin-care-after-a-cesarean/ Twin Births The largest clinical trial ever on twin births found that “twins don’t do better with planned cesarean delivery than with planned vaginal birth when the first baby is in a good position. Death or serious neonatal morbidity occurred in 2% of cases either way the birth was planned.”15 A 2011 review of evidence in Obstetrics & Gynecology found, “When the presenting twin is cephalic, evidence supports a vaginal trial of labor in late preterm and term twins. Routes of delivery for preterm twins lighter than 1500 g remains unclear, with compelling data for both planned cesarean and 14. Dekker R, “Can Hospitals Keep Moms and Babies Together after a Cesarean?,” http://evidencebasedbirth.com/can-hospitals-keep-moms-and-babies-together-after-a-cesarean/ 15. Barrett J, et al. “The Twin Birth Study: a multicenter RCT of planned cesarean section (CS) and planned vaginal birth (VB) for twin pregnancies 320 to 386/7 weeks” SMFM 2013. 16. Christopher D, et al. “An Evidence-Based Approach to Determining Route of Delivery for Twin Gestations” Rev Obstet Gynecol. 2011; 4(3-4): 109–116. 17. American College of Obstetricians and Gynecologists. (2010). ACOG Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Washington DC. 18. Childbirth Connection. http://www.childbirthconnection.org/article.asp?ck=10081 19. Sakala M, et al. “Evidence-Based Maternity Care: What It Is and What It Can Achieve” (October 2008). 20. Institute on Medicine. “Crossing the Quality Chasm: A New Health System for the 21st Century”. Retrieved 26 November 2012. OUR MISSION Our mission is to improve the quality of maternity care in Spokane, WA by providing information and resources to local childbearing families and health care professionals. Bloom Spokane promotes Mother-Friendly maternity care, encourages informed health care decisions, and strives to improve our community’s birth culture. Bloom Spokane is an official chapter of BirthNetwork National, a 501c3 nonprofit organization. Mailing Address: P.O. Box 21005, Spokane WA 99201 Email: [email protected] Website: bloomspokane.org DISCLAIMER The information presented here is for educational purposes only and is not professional medical advice. Always consult a health professional before acting on anything influencing your health and well-being, or that of any minors in your care.