Should we obtain informed consent for vaginal birth?

51F14F16-593A-437A-B0F0-00EFEA0C07E5

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.

We must counsel women about the risks of vaginal birth for the same reason we counsel them about the risks of unprotected sexual intercourse.

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.

  • Glia

    Here’s what I don’t get. I WAS counseled on the risks (to the baby) of a vaginal birth, but only because he was breech. So they explained that I should have a c section and why, including what could happen to him if I didn’t. If the reason you don’t counsel women on the risks of vaginal birth and the alternatives is because it is not an illness or an intervention, then why would that not still apply for a breech baby? Because the risks in that case are to the baby, and not to the mother’s body? So we are allowed to know the risks to our babies but not ourselves? Vaginal birth of a breech baby is still the biological default, and yet, we offer women information about why it is safer to avoid the natural outcomes. The same should apply for the risks of vaginal birth with a vertex baby.

    • Amy Tuteur, MD

      Excellent point!!

  • FormerPhysicist

    I have learned to explicitly ask about the risks of no treatment, for EVERYTHING I talk to any doctor about. Pregnancy, birth, thyroid, high blood pressure, dental fillings, sprained ankle, … anything. Luckily I’m in the Boston area, and doctors are willing to talk about it. But, even here, they often don’t bring it up and don’t list the pros and cons of each option (only compare treatment options).

  • keepitreal

    Ask your OB. C-Section births are so often vilified, but go ahead and inquire as to the long-term effects vaginal births can have on a pelvis. If you have one like mine, they’ll be straight forward and honest. There ARE risks to delivering vaginally and this article is spot on. They ought to be shared with the mother, if for no other reason than she can say she was warned and have the option to deliver surgically. Her body. Her choice.

    • rox123

      I had an OB that said it was pregnancy that caused POP and incontinence, not the birth. He said I have no idea how many women regret their c sections and would have wanted a VB.

      • EmbraceYourInnerCrone

        Ok but how many of those women have had both a CS and a vaginal birth? I have only had a vaginal birth. I would have preferred a CS. My kid weighed 9 pounds and was in distress. I ended up with a vacuum extraction. Two tears and a episiotomy
        I have stress incontinece and after the birth sex was painful for months. For several weeks I could not sit or stand comfortably. A CS pre-labor might have been a lot less stressful on my kid as well…

        • Merrie

          I had a vaginal birth with my nearly 9 pounder, but he was my third baby (older two sibs weighed closer to 7 1/2 lb). That would have been rough if he’d been my first. I have a new respect for my own mom–I’m the firstborn and weighed 8 lb 10 oz.

      • Mel

        And presumably some percentage of women regret their vaginal births and would have preferred a C-section. There’s a vocal sub-set of people who are really into pushing “natural birth” as the cure for everything that ails women so pushing an OB for a VB after a C-section is worth brownie points if nothing else. Pushing for a CS after a VB is not idolized so many women may never ask…..

        I never asked directly (because it would have been insanely inappropriate) but there were quite a few near-term or term babies in the NICU whose moms underwent vaginal births from hell.

        My C-section made my lower abdomen sore for a week or so and I needed to stop and think about how best to get into and out of a wheelchair to care for my son – but I was pretty comfortable sitting for long periods, laying flat all night or standing for short periods of time.

        Moms who had vaginal births from hell were sitting on ice packs and donut cushions along with their pain meds and they looked like they had been through hell.

        • rox123

          I know what you mean, I only saw one VB mother during my stay in the hospital and she was sitting on a doughnut and telling the sheer horror that lasted four hours, without epidural because she wanted a very natural birth. She also said that, pain aside – the experience was bad because she felt that the life of the baby was all in her pushing and she was all exhausted and extremely stressed. This was telling to me because I keep hearing those women that push VB that in a CSection you don’t participate in the birth and it makes you feel useless or ‘less of a mother’, but this woman’s recollection had nothing about the pride she felt participating into the birth of her baby.

        • Glia

          Same. Actually, I did so well that by my second day on the maternity floor, I was mistaken for a visitor by the front desk people, who see moms who just gave birth all day. One of the hardest parts of my recovery was actually remembering to take it easy. I felt so good I was at risk of over-doing it!

      • BeatriceC

        Right. Because my torn urethra was caused by the pregnancy itself and not the frantic and drastic measures with various vacuum and forceps techniques my doctor employed to free my child before he died.

        • rox123

          I had no idea that could happen until now.. Sorry you went through that.

          • BeatriceC

            It’s finally, after 19 years, getting fixed. At 42 I can’t even walk without wetting myself, let alone run or jump or sneeze. But I finally got a doctor that took me seriously and surgery is scheduled for July.

      • MaineJen

        This argument has always seemed to me ridiculous on its face. How could ‘pregnancy’ do as much damage to our lady bits as…well, a baby squooshing its way through there? I mean…you’re going to have stitches either way, it’s just a matter of where they are.

        And yes, ice packs were my friend for a while there 🙂

      • Cartman36

        Ugh, how patronizing. I don’t regret my c-sections at all. im just glad my babies are alive

      • Madtowngirl

        I don’t regret my CS. My baby and I both survived the birth. I originally wanted to try for a vaginal one, because I didn’t want to recover from the surgical incision, but I don’t regret it. If I give birth again, I’ll probably have an MRCS because the statistics are just too high of a repeat CS anyway for my taste.

  • The Computer Ate My Nym

    I personally think there should be an informed consent process at the first prenatal visit to make sure the person in question knows what they’re getting into and is okay with taking the risks of pregnancy–and offer termination if they aren’t. Pregnancy can kill and maim and I’d be hesitant to approve a treatment that was as risky as pregnancy, especially for use in adolscents and young adults.

  • Mock Turtle

    I think you’re wrong on this one, Dr. Tuteur. “One man’s rights is another man’s responsibility.” I’ll happily concede that vaginal delivery can cause harm, and that the risks are much more common (as outlined by Kavin above). But the fact that it is not the doctor effecting it is very important.

    I have no problem with women choosing caesarean, even if it means in 50 years time it is the most common way of giving birth. But it is the natural history of a physiological process. Suggesting “consent” should be given frames the doctor as somehow culpable for doing absolutely nothing, and that makes it clear what a sham this would be legally. It is like one of these ridiculous Human Rights convention statements – “every child has the right to an education” – OK, so who are you going to sue if a child ends up not being educated?!

    If a woman wishes to speak to an obstetrician about the pros and cons of different modes of delivery, well and good. Give them all the information, including risks of vaginal delivery. But it’s a dystopian state of affairs that has women suing doctors because they didn’t feel the possibility of pelvic floor damage from a normal vaginal delivery was communicated to them.

    We consent people for lifesaving cancer surgery, even if it is their clear and only chance of cure, but we don’t “consent for” dying of cancer. Neither do we “consent for” developing haemorrhoids over time, despite the fact that, just like an SUV, “eventually every asshole gets one”! When I do, can I sue my proctologist for not at least discussing the option of a prophylactic colostomy? Come on.

  • fiftyfifty1

    They fear opening the floodgates. If women knew the truth, how many of them would choose CS? How much would the CS rate go up? The official stance is that the CS rate is already too high.

    • Madtowngirl

      And you know, I’m not an expert, but I really don’t think the CS rate would increase that much. Most women recognize that CS is major surgery, and many would prefer to avoid it. Women are smart enough to make these decisions. Kavin really emphasized that you can’t really give informed consent when a woman is exhausted.

      Personally, had I been given a list of risks and benefits about vaginal vs CS delivery before I was in a state of panic after my water broke, I would have still opted to try for vaginal delivery as long as it was a safe option. Other women may not want to risk the chance of tearing, especially if their baby is large. And I think that should be a perfectly valid reason to opt for CS. I mean honestly, why are we so concerned about high CS rates anyway? I suspect it’s a matter of money, rather than the woman’s health. But it looks less douchey to frame it as a “health crisis.”

      • Merrie

        Money and healthcare system utilization. If you get a lot of planned CS, you have to find time to work those into the schedule, and those moms will typically stay in the hospital longer, requiring more beds and staff on postpartum.

        I am curious about the effect of pelvic floor PT, which I haven’t really seen addressed in this discussion (at least not here). Do these stats on lasting incontinence include women who’ve tried and failed PT or was it not even offered?

        • Dr Kitty

          Physio is not going to meaningfully treat levator ani avulsions, large prolapses or OASIS.

          It helps for mild prolapse and may improve pelvic floor strength. It doesn’t do more than improve symptoms slightly or slow an inevitable deterioration over time for most women.

        • Azuran

          It probably wouldn’t be too hard to schedule those, or in any case, wouldn’t be any more trouble than dealing with the current variation in birth numbers between days. I mean, the number of women giving birth would stay the same, and it’s easier to plan an elective c-section and spread them around the week and the day than it is to plan for ‘spontaneous births’
          When I gave birth, we were only 2 women in the whole yard. So they had a lot of staff that got paid to stand around doing nothing that day and a lot of empty rooms. And yet somehow we both ended up requesting epidurals at the same time, and then we both needed emergency c-section at the same time so I had to wait 30 minutes before I could be transferred to the OR.
          And then the next day it was birthpocalypse and everyone and their mother was giving birth and they didn’t have enough beds anymore.

        • Sarah

          The interesting thing is that NICE, who are UK, consider that the cost of offering ELCS to all women who want it isn’t really more than the cost of not. When you factor in that the really expensive births are attempted vaginal, the extra physio etc as a consequence of more prolapses and the legal costs.

        • fiftyfifty1

          The few studies that rigorously examined pelvic floor PT have been really disappointing. IIRC one of them was done in Sweden (or maybe Norway?) and involved actually having women come into the PT office to do supervised pelvic exercises on a weekly basis for months along with making them do the exercises at home and keep a log to track their adherence. Results showed no ultimate difference in urinary symptoms. Other studies have show no improvement in pelvic organ prolapse, which makes sense because much POP is caused by actually avulsed muscles (levator ani etc.) You can’t strengthen a muscle that is literally no longer attached to its moorings. Also studies find no improvement in fecal incontinence. Now there are a myriad of oft-cited studies that claim urinary improvement with kegals, but all of them (except for the Swedish study I mention above) are really poorly designed. With almost any intervention that targets self-reported and hard to measure symptoms, people will initially say they experience improvement, but later this effect goes away. So all sorts of interventions from kegals to acupuncture to pills have been associated with an initial perceived improvement in urinary incontinence. But it doesn’t last.

          TLDR: It’s quite possible pelvic floor PT doesn’t work at all for childbirth-associated urinary, bowel and prolapse symptoms.

      • Ashley Ann

        I see what you did there: “most women are smart enough to make these decisions.” That must mean that women who choose c-sections are dumb? Aren’t you so superior?

        • Madtowngirl

          Reread my comment. I said “MOST women recognize that CS is major surgery.” I did not say “most” women are smart enough, I said women, period.

          And I ended up with a CS anyway. It was the safest option. And yes, that was a decision I CHOSE.

    • Cartman36

      This was addressed in the case of Montgomery V. Lanarkshire Health Board where a woman was not offered a c-section and her baby had shoulder dystocia resulting in cerebral palsy.

      “Dr. M…expressed the view that “it’s not in the maternal interests for women to have caesarean sections”. Whatever Dr. M. may have had in mind, this does not look like a purely medical judgment. It looks like a judgment that vaginal delivery is in some way morally preferable to a caesarean section: so much so that it justifies depriving the pregnant woman of the information needed for her to make a free choice in the matter. Giving birth vaginally is indeed a unique and wonderful experience, but it has not been suggested that it inevitably leads to a closer and better relationship between mother and child than does a caesarean section.

      In any event, once the argument departs from purely medical considerations and involves value judgments of this sort, it becomes clear…that the Bolam test, of conduct supported by a responsible body of medical opinion, becomes quite inapposite. A patient is entitled to take into account her own values, her own assessment of the comparative merits of giving birth in the “natural” and traditional way and of giving birth by caesarean section, whatever medical opinion may say, alongside the medical evaluation of the risks to herself and her baby. She may place great value on giving birth in the natural way and be prepared to take the risks to herself and her baby which this entails. The medical profession must respect her choice, unless she lacks the legal capacity to decide… There is no good reason why the same should not apply in reverse, if she is prepared to forgo the joys of natural childbirth in order to avoid some not insignificant risks to herself or her baby. She cannot force her doctor to offer treatment which he or she considers futile or inappropriate. But she is at least entitled to the information which will enable her to take a proper part in that decision.”

      https://www.supremecourt.uk/decided-cases/docs/UKSC_2013_0136_Judgment.pdf

    • Jennifer

      So they believe that c-sections are so much better that, if she had the choice, every woman would choose them?

      • fiftyfifty1

        “So they believe that c-sections are so much better that, if she had the choice, every woman would choose them?”

        I think it’s a mixed bag what they believe. Some OBs do think they are better (at least for small families) as shown by the fact that when the time comes for them to make their own decision, OBs have a high rate of maternal request CS. These “I got the chance to choose for myself” OBs tend to be supportive of their own patients being allowed to make their own choices too. But other OBs definitely do not think CS is better and are afraid that if women are counseled about the risks of both types and are allowed to choose, that many will feel pressured into CS because it is safer for the baby.

  • Absolutely – Dr. Caughey should be ashamed of his position as a healthcare provider and it demonstrates a remarkable lack of respect for women, their bodies and their rights, as patients. If the goal of quality care is to promote health and well being, then failure to inform is failure to provide quality care. If a doctor fails to inform a patient of the risks of lifestyle choices, they would be failing to promote health and well being by facilitating their patients to make different choices.