Monday, December 16, 2013

Patient Choice Cesarean, Urgent/Emergent Cesarean or Forced Vaginal Delivery - Is it Really That Hard to Choose?

There's a phrase I hear from healthcare providers and others who oppose patient choice cesarean, "No physician is obligated to perform a procedure that he or she thinks is not medically indicated."

They see the denial of choice as being justified. Perhaps they think that they are saving the healthcare system resources by denying the choice. Perhaps they worry that women are unable to make an informed decision in this regard. Perhaps they see performing a cesarean without medical indication as causing harm, to either the woman or the child.

For whatever reason, there are those, who when faced with performing a patient choice cesarean, will outrightly refuse to undertake the procedure.

This would not be problematic if timely access to an alternate provider who is willing and able to undertake the cesarean can be realized. Unfortunately, under the current system - this is often not possible.

So if a woman cannot access patient choice cesarean when it is needed (either planned at 39 weeks or done urgently after the commencement of labour) - what will happen to the patient?

Perhaps care providers simply haven't thought about this in full - what happens to the woman, pregnant and desiring of a cesarean who is not provided timely access to one? What really happens?

Nature is a cruel wench - she isn't particularly patient, and the woman cannot just delay delivery until she finds a provider and a facility who can accommodate. The woman will eventually go into labour - this is nearly guaranteed. Either a medical need will then arise for a cesarean - in which case an urgent/emergent one will hopefully be provided - or medical need won't arise and at some point the woman will be fully dilated, and given no choice as to what she will have to do whether she wants to or not. She will deliver vaginally. The experience of which is foreseeably traumatic - or at least should be - as the patient will have been subjected to what can only be considered a Forced Vaginal Delivery or an urgent/emergent cesarean where either her life or her baby's is put at risk.

And the thing with traumatic experiences is that they don't just go away - and sometimes they don't ever go away. The physician will have avoided doing what he/she saw as a medically unneccessary procedure - but in so doing will have likely inflicted a rather large emotional toll on a woman as she is entering a very significant life transition.

I can speak to the experience of forced vaginal delivery as it is my own lived experience. I can speak to the toll it has taken on me, and how it has changed me and how having had that lived experience - I would not wish it on any other woman because it is it's own kind of hell.

That is the real choice facing health care providers when women come to them asking for a patient choice cesarean: Do you facilitate the request after having provided informed consent, or do you subject your patient to a Forced Vaginal Delivery or an urgent/emergent cesarean after medical need arises?


  1. Your reader

    Mrs. W,
    It's a great coincidence that you have just posted on this topic because I have been wondering about two aspects of this problem.

    How can the doctors explain this away to their conscience that by refusing an ELCS they are forcing a trauma upon that woman with 99% certainty? Probably a lifelong trauma that will affect her and her family? Do they have a conscience at all?

    Another question, maybe a silly one, I have been wondering about, is how can they actually make a woman give birth vaginally if the woman totally refuses to cooperate? If she for instance refused all vaginal exams and let the doctors only listen to the baby's heartrate on her belly? What would they do then? It's kind of hard to give birth with your legs firmly together.
    I know it's a silly question, but I can't imagine how they would do it. I haven't given birth yet and I also never intend to if it's not an ELCS. I'm asking this because I'm trying to make a back up plan in case I accidentally get into the hands of someone that doesn't agree with CDMR. Are we really so powerless against them?

  2. Legs firmly together while you are in excruciating pain and being told cesarean isn't available? Not co-operating doesn't seem feasible to me - it certainly didn't seem feasible at the time. They said no cesarean was available, fully dilated, worse pain of your life - what choice? In order to deliver by cesarean you must have people willing to perform it, and I wonder how nice they'd be about it otherwise.

    I think they think women will just get over it. That they'll have a healthy baby, and just get on with it. I think they think there's nothing a woman can do otherwise anyways.

    For the time being, I think the best you can do is clearly communicate with your care provider and discuss with them your concerns and what you can do should you wind up with someone who doesn't agree with CDMR. It depends where you live, the hospital policies, etc.

    Ultimately though, you'd have to do the best you can under the circumstances you're given and hope that the circumstances change so that the risk of having to undergo a delivery you don't want is absolutely minimized.

  3. Mrs. W, thank you for your answer.

    I can't get it around my head that the doctors would risk the life of the baby just because they want to have their way with the mother and force to give birth vaginally. I guess that a woman who doesn't cooperate in ANY way actually endangers the life of the baby which the present healthcare providers should be concerned about, but maybe they really don't care because if that indeed happened and the baby died they can blame it on the mother anyway.

  4. I've spent most of the last 3.5 years trying to wrap my head around it, and each time I do, I come to the same conclusion: How for the love of all that is good, can this possibly be?!?! That life is sometimes cruelly unfair, and that this is a taste of what hell is. I'm not sure if I can change it, but I'm sure as the hell am not done trying yet.

  5. Mrs. W.

    I'm really gratefull for all your efforts regarding this issue. I'm your fan:)

    In my opinion, it is not only unfair and cruel when doctors do this, but it goes against common sence. My guess is that it is in fact rooted deeply in misogyny, stereotypes and "traditions."

    Another interesting fact is that women who are pro CDMR have to fight not only doctors and their stereotypes or money saving policies, but also other women who often even have the audacity to call themselves feminists, or rather "feminists". Is a woman who wishes suffering upon another woman a feminist? I don't think so.

  6. Thank-you - I'm going through a bit of a rough patch right now, so it's good to know the efforts are appreciated.

  7. You raise a great point about choice: we have very little in Canada. Even the little choice patients have, as a result of multiple treatment options for one condition, seems to get removed by deferring to the most 'cost effective' option.

    We need more people like you who aren't afraid to speak up to get patients' voices back at the centre of healthcare design and delivery.


    Shawn Whatley

  8. Lmao this is the dumbest thing I've ever read. A "Forced Vaginal Delivery?" More like, your body carrying out a process as natural as taking a shit? Are we going to start blaming our doctors for forcing us to pass a huge turd (that was caused by their shitty meat, cheese, and grain diet)? The problem is not doctors that won't hand out c-sections, it's our view on childbirth. What is wrong with our culture that someone within it would actually be traumatized by being "forced" to give birth naturally/vaginally? A woman knowing she needs a c-section to safely deliver her baby is one thing. But being afraid to give birth is a pretty sad excuse. We need to change our worldview, not hand out c-sections. C-sections are lifesaving, last resort surgeries, not privileges. Quit whining and give your baby the safe, natural birth he/she wants. If we were all forced to give birth without doctors (like I have, four times), you'd spread your legs, squat, and shit a baby without even thinking twice. And you'd love it.

    1. This is possibly the most unintelligent and deeply offensive post I could possibly imagine in response to Mrs. W's experience.

      Are you seriously comparing the process of child birth to defecation? I am assuming from your position that you see yourself as a 'home-birth advocate', and if that is the case how could you be so profoundly disrespectful of the birthing process? A process that women in your ideological camp insist on worshiping beyond all common sense, I might add.

      The basis of the argument behind many of the home-birth activism campaigns is that women should be afforded the right to choose the circumstances under which they give birth. It is clear however that you feel that woman's choice should only be respected if that choice complies with your world view. It is just this type of one-dimensional hypocritical thinking that rightfully undermines the integrity of so-called 'direct entry midwifes and home-birth care providers' and their often arrogant, most-times ignorant followers! The fact that you had four successful vaginal births does not speak to your courage, womanhood or personal empowerment, it speaks only to the manner in which your children where born. Nothing more!

    2. You realize that the stance you take seems to imply that you view your children as not being any more important than what you would flush down the toilet. Good to know.

    3. You've given birth four times, so you know what it's like. If doctors could safely teleport your baby directly from the womb to a warm blanket, wouldn't it be barbaric to do otherwise?

      Well, guess what? The future is now. The reality is that a planned c-section is safer for babies and has little or no difference in risk for mothers compared to a planned vaginal birth - and that's ignoring the risks of future surgeries that may be required to treat the potential (and horrifying) complications of vaginal birth.

  9. If a woman can give truly informed consent to an elective Csection, she should be able to have one. The short and long term risks of the surgery (compared to alternatives) are not so overwhelming that the choice is unreasonable. Some risks are higher, some are lower, but the risk profiles for vaginal and cesarean deliveries of healthy babies to healthy moms are close enough to leave it to choice.

    As to deciding to "not cooperate" with a forced vaginal delivery, even by "holding the legs together", that actually made me laugh. In the absence of true size or fetal position errors, the baby will come out. It may or may not be alive or healthy, but birth is inevitable and unstoppable.

  10. Of course a woman can give informed consent - to think otherwise is rubbish!

  11. Being truly informed is not always a given. There is a lot of biased information that is either pro or anti any birth choice, regardless of the mother's and baby's actual circumstances. Falsely informed is common when process is valued over results by meddling outsiders with a platform.

  12. Is "truly informed" the standard to which we hold all decisions that women make? Last I checked, the right to make a medical decision was only conditional upon being competant. A doctor has a duty to advise of the risks and benefits of the treatment options available and to allow for any questions the woman may have - but ultimately the woman needs to be able to retain control of the decision. Any other approach reeks of paternalism and robs women of a very important part of being a "full status" human.

  13. I would hope that "truly informed" is the standard. You know, where the doctor advises the patient of the actual risks and benefits of whatever treatment/course of action/procedure is available to treat the patient's condition, and responds honestly to any questions. Without informing the patient truthfully, how can the patient make any competent decision?

    When doctors/care providers neglect the duty to inform, can the patient give truly informed consent?