When to say no to a C-section: how to talk with your doctor about your delivery options

“Labor is an intricate dance of hormones, muscles and emotions,” writes Dr. Carla Keirns in her essay, Watching the Clock: A Mother’s Hope for a Natural Birth in a Cesarean Culture, featured in the January issue of Health Affairs.

Health AffairsGiven this telling description, it’s easy to see why obstetrics is arguably one of the most high-stakes areas of medicine, since health decisions made for an expecting mother directly impact the health of the unborn child.

In her essay, Keirns notes that the average age of expectant mothers in the United States has increased in recent decades as women choose to delay children until later in life, thus increasing the chance for pre-existing medical conditions that can complicate pregnancies. At the same time, the rate of cesarean sections performed has increasingly grown in the U.S., likely owing to age and a number of other factors. While cesareans can be life-saving for mother and baby in certain situations, some think many doctors are becoming too reliant on the procedure over natural birth.

Keirns, who specializes in palliative care and clinical ethics and is associate director for medical education at the Center for Medical Humanities at Stony Brook University in New York, became pregnant at 40. Due to her diabetes, Keirns’ pregnancy was monitored closely by her doctors, who decided to induce labor just shy of 40 weeks into the pregnancy in order to minimize the risk of stillbirth. Although Keirns was adamant about having a natural birth barring emergency circumstances, as her labor advanced she found herself in a hospital bed surrounded by doctors pressuring her to opt for a cesarean delivery, even though she felt the medical reasoning was not there.

I had been in the hospital for two days in induced labor, unable to get out of bed or eat, almost twenty-four hours on an oxytocin drip. Doctors and nurses shuffled in and out of my room, many wearing worried expressions. They wanted to start magnesium for suspected preeclampsia, a potentially life-threatening complication from pregnancy, but couldn’t prove whether I had the condition because the baby’s head was causing bleeding from my bladder. The doctors started to talk about stalled labor, a stuck baby, and going to the operating room. I had assisted at dozens of caesareans when I was a medical student, but I didn’t think we were there yet. More time. I just needed more time, I thought, as I started flipping through numbers on my mobile phone, looking for friends from medical school who were obstetricians and pediatricians now. I needed another opinion.

After three days of labor and intense monitoring, mother and baby came through safely. But the experience made Keirns consider what could have been done differently and how might her experience help others without her medical expertise.

The NewsHour spoke with Dr. Keirns about her experience and what changes she believes must be made in obstetric intervention policy in order for mothers to exercise greater control in the delivery room.

NEWSHOUR: First off, what benefit does vaginal birth offer to mother and baby, as opposed to cesarean?

CARLA KEIRNS: It depends on the mother and baby’s condition, but for women and babies who have not had complications or compelling medical reasons to have a cesarean, vaginal birth offers women a quicker recovery, a reduced chance of injury from surgical site injuries and a reduced chance of infection. For the baby, risk of injury is smaller but there’s a slightly increased risk of neonatal respiratory distress in babies born by cesarean rather than vaginal birth. That’s predominantly seen in babies whose mothers have not labored because the amniotic fluid is actually squeezed out of the baby’s lungs in transit through the birth canal.

For me, I would certainly have another hospital delivery because my medical history calls for that. But I would want to make sure that I had had that kind of conversation with my doctors and that I had heard their concerns as well as them hearing mine.NEWSHOUR: Then why has cesarean section become so prevalent in the U.S?

CARLA KEIRNS: Cesareans have become much more common over the last approximately 40 years for a variety of reasons. There have been a lot of reviews and a lot of questions raised about that. Some people think it’s because our pregnancies are higher risk. Some people think it’s because we’ve reduced our use of forceps, which a number of people have pointed out are much harder to teach obstetricians to use — it’s more of a hand feel and a craft skill, whereas most situations that would have previously required forceps can be handled with a cesarean. There are a variety of technical reasons and reasons having to do with practice style, and then there are the folks who say that it has to do with convenience for the mothers or doctors, or scheduling or even the fact that some docs may be paid more for cesarean than a vaginal birth, although that varies tremendously.

NEWSHOUR: What can women with less medical expertise than you do to exercise more control in their own deliveries?

CARLA KEIRNS: The first thing is choosing a health care provider whose philosophy matches yours. As several people have written to me since my article was published, you might want to make sure that everybody who shares their call cycle or everybody in their medical group shares your philosophy because of course if they share calls then it may not be your doctor who does the delivery. Women do better with childbirth education, for sure. There are everything from hospitals to Lamaze and other organizations to a variety of groups that try to help empower women with information. In New York, there’s a unique resource. New York state’s Department of Health’s Maternity Information system provides hospital level information on intervention rates. Everything from cesareans to vaginal births after cesareans to episiotomies (an incision made to open the birth canal for the baby to more easily pass through), so you can find out what does the average practice pattern look like in the place you’re considering delivering and see whether you might consider a different place if it concerns you.

NEWSHOUR: Would you like to see something like that expand to the rest of the country?

CARLA KEIRNS: It’s a helpful tool. There’s good evidence for the use of doulas in labor, both to provide support to the pregnant woman and also to bring some expertise. The downside is sometimes they’re not covered by insurance and since you’re talking about someone who’s going to stay with you through labor, it can cost several hundred dollars or more. So a lot of women will not choose that. The issue about midwives has come up of course also. At least in this country, my experience is that most of the midwife groups won’t work with high risk women. Some folks have argued for a partnership model between high risk obstetrician and midwives so that the high risk obstetrician can focus on the medical side of things and the midwives can focus on the obstetric pieces. This isn’t my area, so why there aren’t more partnerships like that, I couldn’t say. But it’s an interesting model.

NEWSHOUR: What can or should obstetricians do to make prospective mothers more aware of their options in regard to their own delivery?

CARLA KEIRNS: Talking about the delivery plan and making a delivery plan together before the women is at the hospital is something that I think all good obstetricians do. But making sure that the plan includes discussion about what to do if there are complications and how to proceed — I’m not so sanguine about women putting together birth plans on their own because, for example, I practice palliative medicine and I see a lot of living wills. Often they’re either not relevant to the clinical situation at hand or simply not feasible in the situation. I’ve heard obstetricians say the same thing about birth plans, and I can see why. It has to be a collaborative planning process.

NEWSHOUR: What is the biggest change you would like to see in obstetric intervention as the number of women giving birth later in life grows and more preexisting conditions arise?

CARLA KEIRNS: The American College of Obstetrics and Gynecology, the Society for Internal Medicine and NIH have put together some excellent evidence-based guidelines for how to manage labor and delivery. They mostly call for using objective data to make decisions and for recognizing what the normal process for labor and delivery are. Obviously guidelines can’t be applied in a cookie cutter way to every patient, but if doctors aren’t going to use them there should be a good reason why.

NEWSHOUR: What’s your biggest takeaway from this experience?

CARLA KEIRNS: Well, besides my beautiful little boy, it would be that mutual respect between patients and their healthcare providers is really key for good medical care. Not just being nice, but also communicating all of the relevant clinical information so that decisions can be made on the best possible basis. For me, I would certainly have another hospital delivery because my medical history calls for that. But I would want to make sure that I had had that kind of conversation with my doctors and that I had heard their concerns as well as them hearing mine.

NEWSHOUR: Is it realistic to think women with less medical expertise than yourself can achieve the same satisfaction?

CARLA KEIRNS: I think it’s very possible. I may not be an obstetrician but I do teach medical students and residents about communication with patients and there are a lot of good ways of making sure that patients understand what they’re hoping for and what might happen that they don’t want so that they can make good decisions about both. It’s the responsibility of physicians and other healthcare providers working with pregnant women to make sure they feel informed, empowered and heard.