While pregnant with my daughter in 2011, I learned—through the internet and childbirth classes—that our bodies are designed to give birth, and that birth is a natural process that should be trusted. Then I had a forceps-assisted delivery.
Nearing my due date, I was 28, healthy, had gained about the right amount of weight, exercised regularly, and my baby was in the ideal head-down anterior position—in other words, my pregnancy was considered low-risk.
My water broke in the wee hours of my due date and, hours later, with no sign of labor beginning on its own, I was given Pitocin, a drug used to induce contractions. Since my membranes were already ruptured, there was an elevated risk of infection if the window between water breaking and the baby’s birth was too long, as the membranes are a barrier to fetal infection.
When contractions began and I was fully dilated, it was time to push. The nurses were kind and encouraging, but after two hours of pushing to no avail, my baby had barely budged and was showing signs of fetal distress, including an abnormal heart rate and elevated maternal temperature.
At this point, the doctor strongly advised a forceps delivery for the safety of my baby. I was not in a state of mind to consider the implications as carefully as I would have even an hour earlier. I nodded and breathlessly said yes. Only in retrospect did I realize that, in my recollection, no one during my labor suggested a Cesarean as an option or explained that forceps would be on the table if things went downhill.
Forceps, which ACOG describes as looking “like two large spoons,” are used when there are concerns about the baby’s heart rate patterns during labor, the head stops moving down the birth canal after pushing for “a long time,” or if a medical condition in the mother (like heart disease) prevents safe or effective pushing. ACOG states that one of the main benefits of assisted vaginal delivery (forceps or vacuum) is to avoid Cesarean delivery, as C-section “is major surgery and has risks, such as heavy bleeding and infection.” And that’s true. What’s also true is that assisted vaginal deliveries, like with forceps, also come with risks—risks that I wasn’t fully aware of when I agreed to the procedure.
My nebulous understanding at the time was that forceps are used extremely rarely if the baby is in distress or if there's an emergency. I gleaned this understanding from a few brief conversations with my doctor and other care providers at my clinic during my pregnancy lasting, in my estimation, less than two minutes each, plus a few minutes of lecture during a childbirth class offered through the hospital, and another brief conversation near the end of my pregnancy.
My husband still recounts his horror seeing the gleaming forceps, which I was too weary to examine. Despite the epidural I had received earlier, I felt excruciating pain and the sensation that my body may tear apart.
My first sight of my daughter is forever etched in my mind: primordial and angry, the 6-pound, 9-ounce creature emerged with a double nuchal cord (umbilical cord wound twice around the neck) and with a what's called a “true” (tightly-pulled) knot in the cord. Drained of energy by the last few hours, and especially the final minutes before she was born, I could barely muster the will to bask in the joy of her arrival.
My daughter is a perfectly healthy first-grader now, and I haven’t suffered permanent damage to my pelvic floor structures. I even had another vaginal delivery with my son in 2013, which was drastically different—it took 45 minutes, and it was gratifying to feel him move with every push.
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. I don’t blame my care providers for using forceps—they were following standard guidelines. But knowing what I know now, I’m disturbed by the fact that I agreed to a serious medical procedure without fully understanding the potential implications. The experience has opened my eyes to the issue of consent—or possible lack thereof—in obstetrics and childbirth.
There are known risks to all births, vaginal or Cesarean, and there are multiple factors that will affect those risks. Here’s what I wish I’d known about those risks before going into labor.
The risk profile varies from mother-to-mother, depending on obvious factors, like whether the baby is large or breech, and less obvious factors like the mother’s weight, age, time from the onset of menstruation, how many times she’s given birth, diabetes status, and more.
Unfortunately, there are also well documented racial disparities related to childbirth in the United States. According to CDC data from 2011-2013, black women have the highest rate of maternal mortality (43.5 deaths per 100,000 live births) compared to other women (14.4 deaths per 100,000 for women of other races, and 12.7 deaths per 100,000 for white women). The risk of pregnancy-related complications is also tied to race and ethnicity. According to data from more than 115,000 women between 2008 and 2011, the rates of severe postpartum hemorrhage and infection were significantly greater for non-Hispanic black, Hispanic, and Asian women than they were for non-Hispanic white women. For the sake of this story, the data included here is not broken down by race, but it's worth noting that a person's risk profile may vary based on race and ethnicity.
It’s understood that C-sections are generally riskier than vaginal deliveries, which is why doctors recommend vaginal births over C-sections for healthy, non-complicated, first-time pregnancies (like my own). Here’s what the data show.
With a C-section, risks include a longer hospital stay than with vaginal delivery, longer recovery time (it is a major surgery, after all), infection, hemorrhage, placenta problems, uterine rupture, and ectopic pregnancy in subsequent pregnancies. Additionally, if you have one C-section, it’s incredibly likely that you’ll have another C-section for any subsequent pregnancies; according to 2015 data from the CDC’s National Vital Statistics Reports, an estimated 9 out of 10 women who get pregnant after having one C-section will end up having another C-section.
Infection, hemorrhage, uterine rupture—all definitely bad things. But also pretty rare, in spite of the significant increase in relative risk.
Let’s look at some absolute numbers, based on that CDC report mentioned above. The report looks at 2013 birth certificate data from 41 states and Washington, D.C. Report authors estimate that the data accounts for 90% of all births in the United States that year, and they differentiate between primary C-section births, repeat C-section births, vaginal births without previous C-sections, and vaginal births after C-sections (VBAC). Looking just at primary C-section compared to vaginal births without previous C-sections, here’s some of what they found about the rates of maternal morbidity after childbirth:
Maternal transfusions: 525.1 per 100,000 live births for a primary C-section (0.53%), compared to 167.1 per 100,000 for vaginal delivery (0.17%) ICU admissions: 383.1 per 100,000 live births for a primary C-section (0.38%), compared to 64.6 per 100,000 for vaginal delivery (0.06%) Ruptured uterus: 49.2 per 100,000 live births for a primary C-section (0.05%), compared to 6.3 per 100,000 for vaginal delivery (0.006%) Unplanned hysterectomy: 67.5 per 100,000 live births for a primary C-section (0.07%), compared to 11.9 per 100,000 for vaginal delivery (0.01%).
Additionally, a recent meta-analysis in PLOS Medicine looked at one randomized controlled trial and 79 cohort studies, all from high-income countries, and examined maternal outcomes, childhood outcomes, and outcomes for subsequent pregnancies. They found that pregnancy after Cesarean delivery was associated with increased risk of miscarriage (11.03% compared to 9.58%), stillbirth (0.41% compared to 0.32 %), placenta previa (0.48% compared to 0.28%), placenta accreta (0.09% compared to 0.03%), and placental abruption (0.68% compared to 0.5%). C-section is also associated with increased odds of asthma (3.67% compared to 3.05%) and obesity (12.68% compared to 9.1%) in the child.
Looking at this data, it’s clear that for many markers of maternal morbidity, C-sections come with higher risk than vaginal delivery—but the absolute risks of most of those complications are still quite low for the general population.
It’s also important that expectant mothers understand that when it comes to vaginal deliveries and vaginal-assisted deliveries, “lower” risk doesn’t actually mean without risk. And for certain measures of morbidity, like pelvic floor trauma, vaginal and vaginal-assisted deliveries can actually be riskier than C-sections—and the absolute risks of them can be much higher.
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. In some cases, these aren’t noticed right after birth because swelling and other factors can lead to a missed diagnosis or make some injuries truly “occult” (meaning hidden without imaging tools).
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.
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.
My experience made me wonder: Why don't we spend more time establishing informed consent for how we're going to give birth?
With the understanding that every birth can be unpredictable, informed consent would ideally include a comprehensive, ongoing discussion of what procedures a person is and is not comfortable with, including in the event of emergency, and detailing what all of their options would be.
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.”
Magnus Murphy, M.D., the ob/gyn who co-wrote the 2012 book Choosing Cesarean: A Natural Birth Plan with journalist Pauline Hull, says that in an ideal world, women would receive standard unified counseling. “By having a consent, it implies a more in-depth discussion, a more in-depth understanding,” Dr. Murphy tells SELF. “That’s what consent is, understanding the pros, risks, and consequences” of any procedure.
While there are informed consent protocols for C-sections and other childbirth procedures, which may vary by institution, there is no universal consent protocol for planned vaginal delivery. “Informed consent is not obtained for vaginal birth," Aaron Caughey, M.D., professor and chair of the Department of Obstetrics & 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." The thinking here goes that vaginal birth is something that your body can essentially take care of by itself—though that's obviously not always the case.
"There will be risks associated with any route of delivery, whether a woman has a vaginal birth, an operative vaginal delivery, or cesarean birth. But by the time a woman goes into labor, she should be well-informed of these risks because her ob/gyn will have discussed them with her during her prenatal care visits and, ideally, they will have come up with a plan together that respects her autonomy and is medically in the best interest of her and her baby," says Dr. Caughey.
In an interview with SELF, Chavi Eve Karkowsky, M.D., New York-based maternal-fetal medicine physician specializing in high-risk obstetrics, tells us that the issue of informed consent through the birth process is a fascinating and nuanced one. "All experiences that a woman has should be experiences that she feels she understands and has been informed of and has been given all available information of. In most circumstances, a vaginal delivery is less of a procedure and more something the human body does a beautiful job of doing. But because there can be associated risks, complications, and even procedures, all education should be made available to women beforehand whether or not a formal consent process is required."
Consent isn’t just a matter of signing a form in this hypothetical scenario—it’s a dialogue that needs to happen well before the due date. "A true consent needs to include risks, benefits, and alternatives, as per mandated language," says Dr. Karkowsky. "But more generally speaking, one of the most important roles a physician has in these days is to try to curate the medical information—of which there is an infinite amount—and bring to their patient only what is going to be relevant and useful. And that subset of information that is relevant and useful will change sometimes by the week, sometimes by the day, sometimes by the minute."
Dr. Karkowsky clarifies that this doesn't mean physicians should withhold information from a patient, rather that too much information can be overwhelming and unproductive. "The surplus of information is almost as misleading as the absence of information," she says.
Dr. Karkowsky tells SELF that, in her experience, the introduction of forceps or vacuum-assisted deliveries during childbirth is relatively rare, but when it does happen, it often happens in a situation where there isn't time to have a thorough discussion of the risks, benefits, and alternatives. In these cases, informed consent is still necessary, but it may need to happen quickly and verbally. "Part of the informed consent process is the relationship and ongoing communication between the patient and her doctor to make sure that if some procedures become more likely that they will need to be addressed in a more thorough way," says Dr. Karkowsky.
Implementing effective informed consent for all potential delivery options as the universal standard in obstetrics won’t be simple. For one, the time constraints involved in the in-depth patient-physician conversations required for more robust informed consent, even with the standard frequent checkups throughout a typical pregnancy, pose an impediment—but something has to give.
To be clear, nobody is advocating for all women to request C-sections, or saying that all women who give birth vaginally or with forceps are left with long-term injuries.
Most women who gave birth vaginally aren't walking around with chronic injuries or incontinence. But some are, and those people are finally talking about the effect it’s had on their lives.
“The whole pelvic floor issue has always been present but it is only very recently that women have become brave enough, and social media has made it more culturally acceptable, to openly discuss what is happening to their bodies post-birth,” Hull explains.
A shift in discourse “is going to happen,” Dr. Murphy says, “but I think it’s going to take a long time.” For now, patients who want to know their options may have to push for these discussions.