Informed consent for childbirth — why are women left in the dark?

During the years I was in clinical practice, I would see women within a few weeks of their vaginal deliveries with severe urinary incontinence (leaking of pee) even after normal, uncomplicated vaginal deliveries. These women were often told by the obstetrician, after the fact, that leaking of pee is not unusual after a vaginal delivery and it should get better. Some women accepted this while others sought further care from a urologist such as myself.

The question that inevitably came up was, “if leaking of pee is common after delivery, why was it never mentioned in any of the prenatal discussions or classes.” I was unable to answer that question. For some women, in the absence of being warned about the possibility of leaking pee, they came to the conclusion that the physician did something wrong during the delivery — a perfectly reasonable conclusion from their perspective but usually not the case.

My son was delivered vaginally during my urology residency. It was a fast uncomplicated delivery. I had no leaking. It never occurred to me to consider a elective C-section. During medical school, we are taught all of the reasons that vaginal deliveries are normal and natural and all of the risks of a C-section, a surgical procedure. What was clearly missing was the fact that normal and natural does not mean without risk.

As a woman and urologist it was quickly clear to me that women deserved informed consent about vaginal delivery in the same way that informed consent as is standard of care for all surgical procedures. It may not technically be surgery, but in many ways it is far more traumatic and unpredictable.

I became an advocate for elective C-section — particularly for women who knew they wanted only one or two children. Women deserve to know that they are playing Russian roulette with every vaginal delivery — the most risk with the first delivery. My guess is that most women would choose vaginal delivery but they would do so having been informed that delivering a baby naturally is traumatic to the organs (bladder, urethra, rectum, anus), the muscles and fascia and ligaments of the pelvic floor support and the nerves and blood vessels that supply these structures. They may experience the impact of this trauma as bladder or bowel leakage or pain. These problems may be apparent immediately after delivery, develop later in life or happen at any point in between. With knowledge comes the ability to take preventive actions or take active control of the situation after delivery.

The case for informing women about this reality is articulated brilliantly by CNLoizou[/]. I thank her for her courage in sharing her bewilderment at her recent experience. With the mounting evidence of the impact of vaginal delivery on women over the lifetimes, I had hoped women were getting better information than they were 20 years ago when I stopped practicing urology— particularly with all of the platforms for sharing information. This is not the case. We need to do better.