How Physicians Are Making Decisions in the Delivery Room

Most pregnant parents head into labor and delivery with a set birthing plan in mind, be it a medicine-free vaginal birth, vaginal birth with an epidural, home birth in a tub, or planned C-section. It can be hard when those plans change at the last second. In some cases, the decision to shift from one delivery method to another may be influenced by external factors.

A new study from October 2021 indicates that doctors making high-pressure decisions in the delivery room use methods of thought that are not always in the baby’s or birthing parent’s best interest. Turns out that doctors may make big decisions, such as whether or not to go with an emergency C-section, based on their experiences at previous deliveries.

The research, conducted at the University of Massachusetts (UMass) Amherst, indicates that doctors use simplified decision-making processes called heuristics to aid them under moments of great pressure. For example, if a doctor's previous vaginal delivery had complications, the doctor may think of vaginal deliveries in general as more dangerous, even if the past delivery was an anomaly. This mode of decision-making relies on information that may be irrelevant and unhelpful to the birth in progress. 

While everyone uses heuristic thinking on occasion, relying too much on heuristics can be problematic for doctors. Decisions on the best possible outcome for the patient need to be based on scientific knowledge applied to the specific situation. 

“While heuristics are good for approximating the correct choice under uncertainty, one can imagine why an 'approximately correct choice' can be worrisome in the context of life and death decisions, such as in medicine,” notes study author Manasvini Singh, assistant professor of health economics at UMass Amherst. “Heuristics in the delivery room are particularly concerning, since the health of two patients is on the line, and physicians’ delivery decisions have immediate and long-term effects on the health of mother and baby.”

What Decision-Making Strategies Should Doctors Use?

The results of this study indicate that doctors are very likely unaware of the role heuristics plays in their decision-making process. “Awareness of one’s susceptibility to such heuristics may reduce reliance on them,” notes Singh. “Technology can also be used to unobtrusively course-correct suboptimal physician decisions; however, the proper implementation of such interventions will likely be a challenge.”

There are three main decision-making processes that doctors can rely intentionally upon in the delivery room: the information-processing model, the intuitive-humanist model, and the clinical decision-making model.

The information-processing model relies on the doctor mindfully combining their professional expertise with their knowledge about the patient. The intuitive-humanist model calls on doctors to listen to their "gut instincts." Combining these two models lets the physician use a combination of logical thinking and intuition, helping them avoid mistakenly relying upon heuristics.

Clinical-decision making is a step-by-step process that uses both doctor expertise and the needs and wants of the patient to come to a final decision. After assessing a patient while taking their medical history into account, doctors share options, which may include things like dosing the patient with Pitocin, a synthetic hormone to speed up labor, artificially rupturing the patient's membranes (breaking their water if it has not happened), electing for an emergency C-section, or more.

Doctors explain the pros and cons of each option clearly and let the patient make an informed choice. It's fine to offer a recommendation, but it should be offered without pressure. If the patient is unable to make the choice for themselves, the doctor gathers information from their medical records and their loved ones to help make a decision that would most likely be in line with the patient's wishes.

How To Advocate for Yourself as Patient

Before going into labor, get a solid idea of what your birth goals are. Write them down or share them verbally with your healthcare provider. Continue the conversation throughout labor and delivery, asking for clarifications through the process. 

"[Patient self-advocation] is best initiated during pregnancy," notes Jaimie Zaki, IBCLC, MCD, MCP, a Texas-based certified lactation consultant and birth doula. "Creating a birth plan that you discuss with your provider can open conversation to the what-ifs, and during labor, if something unexpected occurs, you and your provider should be on the same page as to the next steps."

It's important to educate yourself throughout your pregnancy so that you can advocate for yourself in the delivery room. Do your research, ask questions at your prenatal checkups, and learn whether you have any risk factors. Understand the kinds of situations that may lead to an unplanned C-section. 

You may consider using a doula or another support person to advocate for you if you aren’t sure you will be able to while focusing on your labor. Alternatively, Zaki suggests using the "BRAIN concept," where you ask your doctor about the benefits, risks, and alternatives of a decision, before deciding whether to give your consent.