The expression “life is what happens while you are busy making other plans,” often applies in both life and labor. Labor is frequently the initiation for parents into the reality that kids will most often do what they want, in the way they want, when they want and parental control and influence over them is limited. This recognition of the unpredictability of the labor process and a willingness to adapt one’s plan for labor in response to the situation is important for all women intending to labor naturally, as it helps reduce the negative feelings of disappointment or failure that may otherwise develop if the need for medical intervention arises. However, it is equally important for medical staff to recognize that helping laboring women maintain as much control over the process as possible reduces the likelihood that the birth will be traumatic for their patients or that their patients will suffer from postpartum depression and anxiety disorders.¹ Too often, when a natural labor begins to veer off course, to borrow from another common expression, the baby is thrown out with the bath water. The decision to alter course and utilize any medical intervention in the labor process leads to a complete abandonment of all the intentions the parents had for their delivery and a uniform adoption of the traditional medical birth model. This tendency is not usually necessary and often leaves mothers feeling that they in some way failed or that their desired birth was taken from them.

When intervention is truly indicated, a preferable management strategy is a stepwise model. In this model, medical intervention is implemented in progressive fashion, both in terms of the aggressiveness and quantity of interventions. The goal is to utilize the intervention that addresses care goals but interferes with the patient’s birth plan to the least degree and to introduce only a single intervention at a time, to the degree possible given the specific indication for the modification in plans. This method is best illustrated through several real-life examples. However, prior to those examples, it is important to also explore how decision making is approached within the stepwise model. Integral to the stepwise model of intervention is a shared decision-making process, which is borne out in the medical literature as a sound method for making medical decisions that are effective in terms of outcomes and satisfying for the patient involved. This method of decision making is advocated by proponents of a true informed consent dialogue between patients and providers, rather than the typical paper form, sign on the bottom line, style of informed consent which is most commonly performed.

Shared Decision Making

Shared decision making is defined as “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.”² Decisions are made both in respect to the science and the patient’s values. Ideally, this approach should be utilized in all areas of medicine, but it has particular relevance to obstetrics, where there are many “preference-sensitive” situations. These are situations in which there are several reasonable options or where there is insufficient data to definitively recommend a specific course of action or significant “gray” exists because of competing maternal–fetal risks and benefits. Yet, even in these difficult situations, many providers are hesitant to employ shared decision making with their patients due to concerns that patients are either unwilling or unable to participate in these types of discussions or the process will be too time consuming. These concerns, however, have not been validated by the research. With proper education and encouragement, patients have been shown to be more than capable of discussing and making care decisions.³

The Informed Medical Decisions Foundation describes six steps of shared decision making⁴:

1. 
   

   Invite the patient to participate: Often women do not realize that (1) a decision needs to be made, even if that decision simply is to do nothing, and (2) she is able to share in the process of reaching that decision and ultimately that decision is her’s to make. The invitation to participate really should begin long before the onset of labor. Women should be educated about their care throughout pregnancy and encouraged to make decisions regarding what antepartum screening tests they desire, diet and exercise recommendations, and delivery planning. Ideally, the woman and her chosen care provider should have established a nice pattern of working together toward shared goals for her health long before they ever enter the delivery room. As a patient, if one is not invited to participate in care decisions, she should politely but firmly inform her care provider that she desires this and plans to be a part of the decision-making process. If a provider is unwilling to agree with or belittles her request, she should seek out an alternative care provider.

   
   
2. 
   

   Present the options: Typically, women are offered an intervention which they either consent to or refuse. It is rare that more than one or two options to address a particular challenge are presented; however, in most situations there are many possible courses of action. Providers should initially discuss these options in an impartial way, without a discussion of the pros and cons involved. Providers should also ask the patient if she can think of any alternatives that were not mentioned to help foster openness and inclusion. If a laboring woman or her support team finds that all options are not being presented by their care providers, they should clarify for the provider the options presented, as they understood them, suggest any alternatives they can think of, and ask if there are any alternative options that have not been discussed.

   
   
3. 
   

   Provide information on risks and benefits: For each option presented, information on the risks and benefits should be discussed. This sounds simple when initially considered, however, in obstetrics, this process is extremely complex. For one, given any intervention, there are two sets of risks and benefits to be considered, that of the mother and that of the baby. Often what represents a risk for one is done for the benefit of the other. For example, in response to concerning changes on the fetal heart rate tracing, a cesarean delivery may be recommended. The risks for the baby in a cesarean are relatively minimal and the risk of not performing the cesarean in this particular situation may easily outweigh those risks. However, for the mother, there is no benefit of the cesarean for her health specifically, intentionally disregarding the mental health implications of stress over her baby’s well-being and coping with any potential harm that may come to her baby. For the mother, the cesarean carries significantly more risk of physical harm than waiting for a vaginal delivery. Further complicating this particular discussion is the unreliability in fetal heart rate tracings to predict fetal stress and harm. It is important that both maternal and fetal risk and benefit are given equal consideration and care should be taken by the provider to avoid prioritizing one over the other.

   
   

   Another reason discussions of risk and benefit are so challenging is because the simplest way to present options is by making qualitative comparisons; however, the most informative for the patient making the decision is communication regarding the absolute risk of a course of action as it contrasts with the potential benefits. For example, one can easily say that an elective repeat cesarean section is safer for the baby than attempting a VBAC and this is technically a true statement. Many providers present this exact qualification of the risks and benefits of an elective repeat cesarean to patients who have had a previous cesarean and it very quickly ends the discussion concerning mode of delivery because who wouldn’t choose what is safer for their baby? However, this is very misleading and could even be termed coercive because, as previously discussed, the absolute risk of injury to a baby during a TOLAC (trial of labor after previous cesarean) is low, approximately 1 in 1000 births, and the risk of the mother experiencing a significant complication of an elective repeat cesarean, such as a deep venous thromboembolism, hemorrhage with a need for blood transfusion, or hysterectomy, is comparable or even higher than the risk to her baby in a TOLAC.^5,6 In an interesting flip of the previous qualitative assessment, the risk of maternal mortality is also significantly higher in a repeat cesarean when compared to a TOLAC, but again the absolute risk is a much more reasonable way to discuss the frightening topic of maternal mortality. The risk of maternal mortality in a TOLAC is 3.8 per 100,000 deliveries, while the risk in an elective repeat cesarean is 13.4 per 100,000 deliveries, which is higher but to such a small degree that most would not factor this difference in absolute risk into their consideration.⁷ Quoting exact numbers is not necessary in these discussions, but giving some quantitative reference to the qualitative assessments is. A better way to present this information to a patient considering either a repeat cesarean or a TOLAC would be to say that, “while there is no risk-free option to deliver your baby, the risk of serious harm to you or your baby with either option is very low, occurring in only approximately 1 in 1000 births. In a TOLAC, that risk primarily applies to the baby, while in a repeat cesarean that risk primarily applies to the mother. The safest option for both mother and baby is a successful VBAC and, statistically, 80% of women can have a successful VBAC. However, the next safest option is a scheduled repeat cesarean and many women prefer the predictability and controlled conditions of a repeat cesarean over the unpredictability of labor. It is up to me to help you determine if you are a good candidate for a trial of labor and up to you to decide which option seems the most reasonable for you.”

   
   

   Finally, there is a tendency in discussions of the benefit and risk of various interventions to “snowball,” or discuss the possible implications of that option, 10 steps down the line. An example of this would be counseling a patient desiring an early epidural that an early epidural increases her risk of a maternal fever, but rather than stopping there, going on to say that this may mean she is more likely to need pitocin or a cesarean section and her baby may need to be admitted to NICU. If her baby goes to NICU, this may make it more difficult to breastfeed and her baby may also need antibiotics, which may cause changes in the baby’s gut flora which are not yet fully understood. Two or three “risks” down the line, it is hard to remember what the initial risk even was. All the patient hears is bad piled on bad. Snowballed discussions are frightening for the patient and often manipulative, meant however unintentionally to dissuade the patient from a particular course of action. Attempts should be made to prevent patients from feeling overwhelmed by information and discussions of risk should be restricted to the intervention being discussed and its immediate known consequences. If the patient asks for elaboration on other possible outcomes if that complication occurred, it can then be explored, again with proper quantitative clarification.

   
   

   Ideally, risks and benefits of common medical interventions should be explored prior to labor and delivery, during antenatal childbirth education. In this way, women and their partners can think about and consider these interventions outside of the stress of a labor complication. Decision aids, literature, or visual presentations that have been designed to educate patients about the risks and benefits of particular medical interventions and have been studied for their education efficacy are another way patients may obtain valuable information about delivery options during the antenatal period that is accurate, up-to-date, and generally unbiased. Antenatal education keeps intrapartum, in labor, conversations concerning management options and their risks and benefits manageable, as providers are able to reference and expand upon knowledge that the patient already possesses. Patients are able to ask more informed, pertinent questions, from a less fearful position.

   
   
4. 
   

   Help the patient evaluate the options based on her goals or concerns: During these discussions of situations that have more than one reasonable option or where maternal and fetal interests conflict to some degree, it is the patient’s goals and values that should direct the decision-making process and help prioritize the maternal–fetal interests. The provider should provide room for the patient to express those goals and values and offer advice that acknowledges and supports those preferences. For example, in a situation where maternal and fetal interests conflict, a mother with other children and/or her spouse may prioritize her well-being over that of the baby she carries simply for the reason that her well-being is so critical to the well-being of their other children. This does not mean the interests of the baby are not taken into account, but only that, all else being equal, the safety of the mother is the priority. A first-time mother, on the other hand, may be quick to completely neglect her own interests in favor of her child, or a woman or her family may feel culturally or religiously obligated to consider the child first. Again, the mother is not forgotten in this situation, but recommendations may be tailored to what is safe for both yet safest for the baby, even if only to a small degree.

   
   
5. 
   

   Facilitate deliberation and decision making: Doctors and midwives can aid in decision making by expanding on options for care to the degree the patient wishes and encouraging the patient to express her feelings about each option presented and addressing specific concerns. The care provider should provide plenty of opportunities for follow-up discussion and questions, but also provide time for independent consideration of the options by the patient and her family. In an outpatient setting, this can be done over several appointments. In labor and delivery, this is best done by offering the patient time to consider, while the provider steps out of the room with either a promise to return for further discussion after a specific time period or an indication to the patient that they should reach out when they are ready to discuss things further or have reached a decision. Patients should always feel comfortable asking additional questions and asking for time for private consideration before agreeing to any intervention.

   
   
6. 
   

   Assist with implementation: Once the patient makes a decision, her doctor, midwife, or nurse should go about working with the other members of the health care team to bring about that action as quickly as possible or, if that decision is inaction, to communicate that preference to others so she is not further questioned about it in a way that may be interpreted as pressuring.

A helpful decision-making acronym, suggested in multiple natural birth resources, is for patients to use their B-R-A-I-N when considering various medical interventions:

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  B: Benefits—what are the benefits of this option?

  
  
• 
  

  R: Risks—what are the risks of this option?

  
  
• 
  

  A: Alternatives—what other choices do I have?

  
  
• 
  

  I: Intuition—how am I feeling about this option?

  
  
• 
  

  N: Nothing—what if I did nothing for 5 minutes, 1 hour, 5 hours, or a day?

This acronym is essentially a simplification of the shared decision-making steps, but may be a helpful way for some patients to think about problems in labor and possible solutions to them. It can also be a nonintimidating way for providers to guide their patients through shared decision making.

Example 1: Baby Chloe’s Birth, Ineffective Pain Relief and Slow Labor Progress