There is no lack of noise in a delivery room.

Shouts of pain, orders from doctors, questions from family members and, eventually, cries of new life mix with anticipation and joy to create an atmosphere of controlled chaos.

So when a laboring woman has a request, who will hear? And how much power does she wield over her birthing experience?

Communication between doctors and their pregnant patients is critical to ensure a satisfactory birth experience, saidDr. Michael Duffy, medical director at Family Health Services in Twin Falls. Whether a mother wants to give birth naturally while standing or prefers having a painless procedure with an epidural, she needs to make her wishes clear from the beginning.

Amie Taber of Shoshone found that out four years ago when her son was born. She wanted to give birth vaginally. The problem:She had already had a cesarean a few years before.

Taber had no hang-ups about delivering her daughter via C-section - she had experienced irregular contractions and the doctor was worried about her baby - but had no complications when pregnant with her son.

VBAC, which stands for vaginal birth after cesarean, is safe 98 percent of the time, said Taber, an employee of St. Luke's Wood River Valley. That's the rate also reported by M. Enkin et al. in "A Guide to Effective Care in Pregnancy and Childbirth."

But when things go wrong the other 2 percent of the time, it can result in extreme blood loss from uterine ruptures. And because of St. Luke'sWood River Valley's isolation and limited blood bank, some medical staff didn't want to take the risk.

Taber wasn't worried, though, and neither was her doctor. "My position was because of a 2 percent risk, you don't have the right to force me to undergo an invasive procedure when my set of criteria are very good for a VBAC,"Taber said.

Her persistence paid off. She gave birth to her son, now 4 years old, after a short labor and had no complications.

Kimberley Nielsen of TwinFalls also felt strongly about giving birth vaginally. Initially, Nielsen, 39, wanted to hire a midwife, but after developing high blood pressure and other complications, she decided to give birth at the hospital.

In late September, when Nielsen was 39 weeks along, doctors wanted to induce labor and she agreed. She continued to make it clear that she wanted to give birth vaginally.

"I just would rather do it natural,"Nielsen said. "I don't like being cut open."

With help from pitocin - a man-made hormone that speeds up the labor process - and an epidural, Nielsen gave birth to her fifth daughter, Tenna, on Sept. 25.

Tenna, who has Down syndrome, had to spend time in the intensive care unit but is now home with her mom. Tenna's four sisters, all born vaginally, are spoiling the baby, Nielsen reported happily.

Not all women are automatically anti-C-section. When TwinFalls nurse Amy Burton was pregnant with her only child five years ago, she developed preeclampsia at 25 weeks and stayed bedridden for most of the rest of her pregnancy. At 41 weeks, she hadn't dilated and the baby hadn't dropped, so the doctor encouraged her to have a C-section.

Burton agreed, and that evening, she had her daughter in her arms. She didn't regret not having a vaginal birth. Burton was 35 at the time and knew that hers was a high-risk pregnancy because of the preeclampsia and her age.

"I never felt cheated out of a vaginal delivery like some people are," said Burton, now 41. She encourages women who have high-risk pregnancies or who are open to the option to research cesareans.

"Watch a documentary on a C-section. Really talk to your doctor about it,"she said. "And don't fear it. The more you're educated on it, the less there is to fear."

Duffy said women should communicate their wishes to their doctor at the first visit and continue to talk over options throughout gestation. Birth expectations are different for all women, he said, and if you have specific requests, make them clear.

"You might have, in two adjacent rooms, one laboring patient that comes in who states she wants an epidural started right away, and wants her labor to be as painless as possible as her primary goal," Duffy said. "The patient next door might desire to deliver in a squatting position, having had no medications whatsoever, and only intermittent fetal heartrate monitoring."

Dr. Cole Johnson of Twin Falls said women who are pregnant for the first time often don't know they can customize their labor experience. During his first visit with new patients, Johnson asks them to think about labor positions and anesthesia options. He also makes it clear that women have the power to change their minds, even in the middle of labor.

"I try to make them understand that they're in charge,"Johnson said.

Sometimes, a doctor has to recommend against a patient's wish to have a natural birth. Several factors go into the decision to recommend a C-section, Duffy said. Most often, doctors recommend the procedure when the fetus is in distress. Although he has never had to override a patient's desire to avoid a cesarean or pitocin, he often encourages the procedures when he feels the labor isn't progressing fast enough or the fetus's heartrate drops. The fear of malpractice suits is always in the back of obstetricians' minds, and if a cesarean delivery ensures the safety of a baby (and, less importantly, a physician's practice), they will often take that route, he said.

But it's not all about avoiding lawsuits.

"In my years of practice, the single most enriching thing is when I'm able to modify my practice to meet the specific needs and expectations of the patient to make the labor and delivery process unique, uniquely meaningful to that patient and uniquely wonderful for that patient," Duffy said. "To make that happen is an incredibly complicated equation of evidence-based medicine, hospital policy and medical-legal concerns, combined with adequate communication with the patient and the patient's family and adequate nursing staff and support and appropriate use of technology."

"And only when all of those things come together well,"he added, "is the obstetrics experience allowed to be everything it should be for that patient."

Melissa Davlin may be reached at 208-735-3234 or melissa.davlin@lee.net.