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Avoiding the Cascade of Interventions During Childbirth


As healthcare has become more modernized and bodily processes more medicalized, so too has the natural physiological experience of childbirth. Since the first time a woman gave birth millennia ago, women throughout history have been bringing babies into the world intuitively, instinctually, and powerfully. Supported by other women or even birthing independently, mothers have navigated the journey of childbirth with the knowledge that it is a normal function of the female anatomy and physiology, rather than a medical state requiring constant management. But, as the medical model of care grew into the predominant model for all illnesses and injuries, it pulled into its purview the care of the laboring mother, overshadowing and marginalizing the midwifery model of care as antiquated, primitive, even dangerous. Birth became a collection of diagnosis codes and surgical procedures, rather than the empowering celebration of the creation of a mother and child that it is and always has been. It became something out of women's control, something to be feared and thus surrendered to experts.

There is a well-known chain of events that unfolds when the physiological process of childbirth is initiated, augmented, or interrupted by medical intercession known as "The Cascade of Interventions." What this means is, the more we interfere with the body's natural function, the more we will be required to continue interfering as our medical efforts yield additional side effects that further require management. "Almost every intervention has some potential to cause harm. You should use care in deciding whether to have an intervention. We encourage you to accept only those interventions that are more likely to offer benefit than harm." http://www.childbirthconnection.org/maternity-care/cascade-of-intervention/

An often-referred to example of this occurrence is induction or augmentation of labor with Pitocin (synthetic Oxytocin). It should be noted that use of Pitocin to start or intensify labor does not always lead to The Cascade of Interventions, however it is a risk factor and does occur quite often. Pitocin stimulates uterine contractions through an intravenous (IV) medication administered by a registered nurse (RN). These contractions, unlike those occurring when labor begins and progresses naturally, are not regulated in strength and intensity by the body. The strength and intensity of the uterine contractions are regulated by the RN through manipulation of the medication's IV infusion rate. Because of this, it is not uncommon for Pitocin-stimulated contractions to be longer and stronger than those the body would naturally produce and than what might actually be physiologically-needed in a particular birth. Because of this, a few things can happen:

  1. The pain of the contractions may become too intense for a laboring mother to tolerate naturally. In this instance, she may request IV pain medication or the placement of an epidural. Both of these options carry side effects that may result in the need for further intervention. For example, an epidural can cause a decrease in blood pressure, which results in less oxygen delivery to the placenta and, thus, the baby. Treatment may include limiting the mother's options for movement and positioning, administration of IV fluids to increase blood pressure, and, if the baby becomes distressed from decreased oxygen availability, cesarean delivery.

  2. The contractions become unnaturally strong, long, and close together. Contractions constrict the uterine muscles, decreasing blood flow to some degree during their duration. Pitocin administration can cause prolonged lack of oxygen due to the long, hard contractions it produces. Similar to the scenario described above, this decrease in blood flow can cause stress in the baby, identified through the use of continuous electronic fetal monitoring (a requirement for all mothers who are receiving Pitocin). The baby's distress leads to inevitable further intervention to improve the oxygen availability, and could ultimately result in a surgical delivery.

These are only two possible examples of The Cascade of Interventions that may result from just one of the many practices that have been shown to increase this risk. Other practices which carry an increased risk for The Cascade of Interventions include:

  1. Induction of labor (IOL) or augmentation of labor using medications such as (but not limited to) Pitocin.

  2. Artificial rupture of membranes (AROM) or "breaking the bag of waters."

  3. The use of pain medications during labor, including epidural placement.

  4. Laboring in bed, particularly on the back, without changing positions frequently or using upright positions. Mothers who have an epidural placed will likely be required to labor in bed, but there are still ways to move and position in order to continue labor progression.

To many women, these scenarios probably sound terrifying, while others may find the idea of having so many medical options available to them reassuring. If you find yourself in the first group (i.e. the terrified group), you may be asking yourself how to avoid this chain of events. Even if you are not in the terrified group, understanding how to consent to or refuse a proposed intervention is vital to being in control of your care. One of the most important elements to avoiding The Cascade of Interventions is understanding informed consent. I wrote a previous blog post about this topic, but an easy way to remember how to seek and give informed consent (or informed refusal) is to bring your B.R.A.I.N.S to birth:

  1. B: What are the benefits of the proposed intervention? Will the outcome of my and my baby's situation improve if we agree?

  2. R: What are the risks of the proposed intervention? Do the benefits discussed above outweigh the risks and improve the safety of my baby and myself?

  3. A: What alternatives to the proposed intervention are available to me? Is there something safe and less invasive we can try first?

  4. I: What does your intuition tell you about what is being recommended? Do you have a gut feeling one way or the other? Don't dismiss the messages your instinct and intuition are trying to send!

  5. N: Do I have to decide right now? Is this a true emergency or a time-sensitive intervention?

  6. S: Is this proposed intervention safe for my baby and for me? This is a good way to follow up on the question of risk in #2.

There are a number of other ways to improve your chances of avoiding The Cascade of Interventions during childbirth. When you and your partner are putting together a birth plan, that is also a good time to discuss your thoughts and feelings about these options and discuss them with your care provider. These options include:

  1. Delivering in a birthing center or at home. The very nature of these locations and the providers who practice in them renders many of the interventions described above, such as epidural placement and Pitocin administration, obsolete as they are simply not performed in these settings. For some mothers, such as those with high-risk pregnancies, birth center or home births may not be an option. But before you rule them out entirely, discuss these settings with your care giver if you truly desire this type of birth.

  2. Find a care provider whose beliefs align with your own. If you want a natural, unmedicated, un-tinkered-with birth (regardless of your chosen birth setting), look for someone who practices the midwifery model of care. Midwives or physicians who employ this philosophy view birth for what it is: a natural, innate process that all women's bodies know and are made to perform. They utilize a more hands-off, observational approach, also known as "watchful waiting." Interventions they do perform are often less invasive and simpler than those discussed earlier.

  3. Hire a birth doula! This step alone can drastically improve the outcomes of labor and birth, and reduce the occurrence of The Cascade of Interventions. Doulas are non-medical birth professionals, skilled in assisting mothers and their partners/support people with using positioning, relaxation, movement, and non-medical options for birth. The presence of a continuous labor support person has been shown to decrease the use of pain medication, the utilization of forceps or vacuum assistance, and the incidence of cesarean section Doulas also improve the mother's experience of her birth and increase overall satisfaction.

Ultimately, avoidance of The Cascade of Interventions comes down to being an advocate for yourself and your baby. By learning about interventions and their alternatives, by understanding informed consent/refusal, by developing a birth plan and selecting a supportive birth team, and above all else, by being open and honest about your preferences, you can shape this sacred moment and maintain control of your birthing journey.


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