Vaginal Delivery in a C-Section Culture

A recent article in Health Affairs highlighted the pressures some patients who desire a natural or vaginal birth may face in a culture of cesarean deliveries. The article details the experiences of Carla Keirns, MD, PhD, MSc, FACP, when she delivered her first child. As a physician (clinical ethics and palliative care), she knew she needed to advocate for herself and not be pressured into having a c-section on the basis of fear of what could go wrong instead of the medical facts of her case. She also had friends and colleagues she could turn to for second opinions, something most women wouldn't have access to.

The gist of her case, extremely simplified, is that she'd been laboring in an induction for nearly 2 days and the L&D clinicians had started to watch the clock, pushing for a c-section. However, when it finally came time for her to push, the room had yet to be set up for a vaginal delivery and her clinicians seemed unprepared, so much so that the neonatal team wasn't in the room. It seemed to her that she had been written off as a c-section, so no preparations for a vaginal delivery had been made.

The goal of her article is a call for change to the system of care that steers many women toward c-sections in an age where policymakers and clinician groups want to reduce the US c-section rate. Keirns mentions that she fully realizes that if she wasn't a doctor, she would have had a c-section on Wednesday instead of a vaginal delivery Thursday afternoon. The current system of care doesn't support women laboring for extended periods, especially women considered high risk, yet many c-sections occur because of the sometimes-elusive "failure to progress."

"As expectant mothers become older, with more preexisting medical conditions, guidelines need to evolve beyond those for the low-risk mother in her twenties, and recommendations to avoid cesareans must evolve beyond 'choose a midwife instead of an obstetrician,'" Keirns wrote.

In general, women realize the value of an experienced obstetrician. They feel secure in knowing that their obstetrician is capable and ready to handle an emergency should one arise. But women also need to have a say in what happens. Because based on their own experiences, too many women may agree with Keirns: "The principles of 'shared decision making' seemed highly theoretical from the hospital bed."

Can patients who desire a natural birth or vaginal delivery truly participate in shared decision making in a system of care that trends toward c-sections?

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References:

Keirns C. Watching the clock: a mother's hope for a natural birth in a cesarean culture. Health Aff. 2015;34:178-182. Available at: http://content.healthaffairs.org/content/34/1/178.full.