Should we obtain informed consent for vaginal birth?


Kavin Senapathy, writing in Self reports Giving Birth Made Me Question the Informed Consent Process During Childbirth.

The issue: should we obtain informed consent for vaginal birth? After all vaginal birth is natural, not a medical procedure.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We must counsel women about the risks of vaginal birth for the same reason we counsel them about the risks of unprotected sexual intercourse.[/pullquote]

I would pose the question a bit differently. Are doctors ethically required to counsel women about the risks of vaginal birth when they counsel women about the risks of C-sections, forceps and vacuum? The answer is yes and the reason is the same as the ethical imperative to counsel women about the risks of unprotected intercourse: so she can protect herself.

Kavin had a forceps birth for her first child.

My daughter is a perfectly healthy first-grader now, and I haven’t suffered permanent damage to my pelvic floor structures…

All that being said, I don’t know whether I would have opted for a C-section for my daughter’s delivery, but I do wish that I had made a choice in advance of giving birth about which procedure to use in the event of an emergency—a choice informed by a more extensive lay understanding of potential outcomes and risk factors.

She reviews themes I’ve discussed repeatedly.

There are significant risks to vaginal birth:

With vaginal deliveries, there is a real possibility not only of vaginal tearing, but pelvic floor problems that can manifest as urinary incontinence, anal sphincter injury and fecal incontinence, and pelvic organ prolapse.

The meta-analysis in PLOS Medicine found that vaginal delivery is associated with greater risk of urinary incontinence (14.9% incidence after vaginal delivery, compared to 8.93% incidence after C-section) and pelvic organ prolapse (5.99% for vaginal delivery, compared to 1.81% for C-sections) in the mother. According to ACOG, the risks of tearing and urinary and fecal incontinence are higher with assisted vaginal delivery.

The absolute risk of vaginal delivery complications is much higher than the absolute risk for C-section complications:

Here is where an extensive understanding of the various risks might come into play. While an unplanned hysterectomy due to complications from a C-section is generally viewed as much worse and more traumatic than urinary incontinence, the number of women who have the former is significantly lower than the number of women walking around with permanent pelvic floor damage. Ask a woman to weigh a 0.07% risk of unplanned hysterectomy to a significantly higher risk of spending the rest of her life peeing a little when she laughs, coughs, sneezes, runs, lifts, and other general life activities, and her answer might not be so obvious.

Kavin asks doctors for their opinions. Not surprisingly, those who treat injuries from vaginal birth think informed consent ought to be necessary:

Hans Peter Dietz, M.D., Ph.D., professor of obstetrics and gynecology at the University of Sydney, tells SELF that informed consent for emergency procedures can often be overlooked in the time leading up to the delivery. And that’s in stark contrast to the way we treat many other medical procedures. “When I propose a surgical procedure, we talk for at least half an hour, and sometimes several times,” about nuances surrounding individual risk factors and potential outcomes, he explains. But “in obstetrics it’s totally different. We’ve been totally backwards in terms of applying those rules of consent.”

But that view is not shared by all obstetricians:

“Informed consent is not obtained for vaginal birth,” Aaron Caughey, M.D., professor and chair of the Department of Obstetrics and Gynecology at Oregon Health Science University, and vice chair of the ACOG Committee on Practice Bulletins-Obstetrics, tells SELF via email. “Informed consent is an ethical concept designed to respect patients’ moral right to bodily integrity by protecting them from unwanted medical treatment or intervention, but giving birth vaginally is a natural physiologic process that by definition is not medical treatment.”

Dr. Caughey offers three reasons why informed consent is not necessary: vaginal birth does not involve a threat to bodily integrity; vaginal birth is entirely natural; and vaginal birth is not an illness.

I respectfully disagree with Dr. Caughey on all three reasons.

First, continence and sexual function are important aspects of bodily integrity. Vaginal birth can impair or destroy both. If the purpose of informed consent is to respect the right to bodily integrity and vaginal birth has a much higher absolute risk of permanently impairing bodily integrity than C-section, then we are ethically mandated to tell women about those risks and how she can avoid them.

Second, the natural vs. technological dichotomy is irrelevant for obtaining informed consent. For example, when a patient faces a cancer diagnosis, the option to forgo debilitating treatment is a critical option and widely recognized as ethically appropriate. Some patients, prefer to leave their fate to nature. They reject chemotherapy, radiotherapy or surgery and hope they can cure themselves with herbs, supplements or prayer. It is just as important to counsel patients about the risks of allowing nature to take its course as it is to counsel them about the risks of treatment.

Finally, the dichotomy between health and illness is also irrelevant. There’s nothing wrong with a person’s health when she chooses to have unprotected sexual intercourse. And there certainly isn’t anything more natural than the desire to have unprotected intercourse. Nonetheless we consider providers ethically mandated to counsel women about the risks of unprotected pregnancy and sexually transmitted diseases. We believe it imperative to counsel women about different methods of birth control as well as condoms to prevent disease with or without other contraceptive methods.

The bottom line is that providers are always ethically mandated to inform women about risks when they face choices of how to protect themselves. It doesn’t matter if the course of action is the biological default; it doesn’t matter if it’s only the refusal of treatment; and it doesn’t matter if it has nothing to do with illness. Women deserve the information about the risks of vaginal birth for the same reason they deserve the information about the risks of unprotected intercourse. They can’t protect themselves unless they have accurate and complete information.