Increasing patient-centeredness in birth care partly involves understanding of women's decision making. Toward that aim, we assessed how many women reported unanticipated decisions in childbirth, and we examined their written descriptions thereof. Of 70 women recruited in pregnancy, 64 (91.4%) completed a 1-month postpartum follow-up, and of those, 39 (61%) reported having been involved in an unanticipated decision in childbirth. Quantitative analysis revealed no differences between the decision and no-decision group on background characteristics or on pregnancy risk. Thematic analysis indicated that women's views on agency in birth decisions ranged from having decisions made for them to their having had an active role. Nearly all reported decisions centered on a specific intervention tied to an identified medical cause. We discuss providing anticipatory guidance to prepare women for the likelihood of being involved in childbirth decisions while under labor stress.