She came to the hospital with a detailed birth plan tucked neatly into her bag. No epidural, minimal monitoring, freedom to walk during labor. She and her partner had envisioned a quiet, unhurried birth — one where medicine stayed in the background and their baby’s arrival felt as natural as possible. However, with newly diagnosed pre-eclampsia, those plans shifted. Needless to say, this was not how my patient expected her birth story to unfold.
Though she was initially resistant to starting Pitocin, a synthetic form of oxytocin which is used to induce labor, she eventually agreed for the sake of her baby’s safety. For several hours, her labor course was quiet. She received intravenous magnesium for seizure prophylaxis and labored gracefully with Pitocin, swaying with her contractions, her partner’s hand steady in hers. I checked in periodically, watching from the periphery.
Then, slowly, the fetal heart tracing began to change. At first subtle dips, then longer decelerations. I studied the monitor, weighing how much longer we could wait. Many ob/gyns, myself included, acknowledge the limitations of fetal heart tracings in predicting fetal compromise. A large body of evidence also supports that continuous monitoring does not consistently identify which fetuses are truly at risk of acidemia or neurologic injury. But in the context of pre-eclampsia and fetal growth restriction — conditions already known to compromise fetal well-being — my senses were on high alert. Her baby was at heightened risk of decompensation.
Eventually, I entered her room, sat at her bedside, and explained what I was seeing: fetal distress, necessitating even more interventions. Her face fell and her voice trembled — not from pain, but from disappointment. It was the last thing she wanted to hear.
I recommended she get an epidural, not because she was in severe pain, but just in case she required an emergent C-section, she could be awake for the birth of the baby. If she did not have an epidural and required a C-section, she would have had to have it under general anesthesia, completely asleep when her child was born.
She sobbed, “I never wanted any of this.”
I told her I understood — if I had expected a birth free from IVs, continuous monitoring, and the possibility of surgery, I would be upset too. But I also explained that these tools were not a betrayal of her wishes — they were extensions of our shared goal: to keep her and her baby safe. It’s in moments like these that medicine feels as much about communication as intervention.
We adjusted where we could; we kept the lights low, minimized staff in the room, trying to preserve the calm she had hoped for. Her water broke spontaneously, and her baby’s heart rate continued to show signs of compromise. We initiated an amnioinfusion, instilling saline into the uterus to relieve umbilical cord compression. Thankfully, it worked.
In the end, she delivered vaginally — a victory, in my mind. I exhaled, relieved we had avoided what would have been a difficult surgery.
I expected her to share that relief, but instead, she was devastated. She never wanted magnesium, Pitocin, or an amnioinfusion.
“You didn’t care about what I wanted,” she said. And yet, she wanted a vaginal birth, and we achieved that. Had she declined our recommendations, she may have faced catastrophic consequences, including an emergency C-section under general anesthesia, maternal seizures, or neonatal death.
Many patients hope for a vaginal birth because they see it as the more “natural” way to bring a child into the world. But sometimes, a vaginal delivery simply isn’t possible, usually due to the 3 P’s we are taught in medical school: power (the strength and pattern of contractions), passenger (the size and position of the fetus), and pelvis (the maternal pelvis). Nearly every labor curve — whether it’s fetal intolerance, failure to progress, or cephalopelvic disproportion — can be understood through these physiologic factors.
Yet, the cultural narrative around childbirth often romanticizes it as a process that should unfold on its own, untouched by intervention. Historically, people did give birth without medical support, but those “natural” births came with staggering maternal and neonatal mortality. Modern obstetrics exists because for centuries, pregnancy and childbirth were life-threatening conditions. Today, we have interventions designed to prevent devastating outcomes. These tools are not meant to withhold autonomy from patients, but rather to safeguard their lives and the lives of their babies.
While a birth plan can guide preferences, it cannot dictate labor. Pregnancy and childbirth carry a level of unpredictability that no plan can fully account for. Labor can turn quickly, and bodies don’t always cooperate with expectations or desires.
And yet, many patients still do not trust us. Whether shaped by a long history of medical discrimination against women and racial and ethnic minorities, or by the frightening stories they hear from friends and social media, skepticism toward the medical system runs deep. I find myself wrestling with this often. My responsibility is to honor patient autonomy while also ensuring safety: a balance that can feel delicate and, at times, impossible. Even when I make recommendations to prevent harm, there are moments when patients feel unheard or overruled. Reconciling my intention to do no harm with their perception that their wishes are not honored, continues to challenge me.
Ultimately, I have learned that good obstetric care is not only about sound clinical decision-making, but also about communication, humility, and earning trust in moments when patients feel most vulnerable. It requires an acknowledgement of the trauma that comes with a birth story that does not unfold the way a patient hopes.
I may not always be able to give patients the exact birth experience they envisioned, but I can give them honesty, compassion, and partnership. In a setting with vast unpredictability, shared understanding may be the most meaningful thing I can offer.
When have you had to make choices for patient safety that did not align with their initial care plan? Tell us in the comments.
Dr. Vidya Visvabharathy is an ob/gyn in Cleveland, OH. She enjoys dancing, baking, and taking long walks with her husky mix, Lilo. Dr. Visvabharathy is a 2025-2026 Doximity Op-Med Fellow.
Illustration by Jennifer Bogartz
