Reducing the Cascade of Interventions in Childbirth

Maternity care tends to be very intervention focused in America. Most birth experiences consist of IV fluids, restrictive eating and drinking, continuous monitoring, epidurals, and induction or augmentation. It is common for interventions to be recommended to a laboring woman to keep her labor progressing. Some of these interventions have side effects that can lead to even more interventions, leading to  “the cascade of interventions.” Understanding this snowball effect is essential to reduce unnecessary medical interventions which can interfere with your labor progress, as well as your own and your baby’s wellbeing.

Why should you avoid or limit interventions during childbirth?

When we intervene with the natural birth process, the effects of that first intervention may cause a need for another intervention, and so on. For example, if you take a medication and you experience a side effect, that can lead to administration of another medication to counteract the first. This can lead to a series of interventions due to the initial  reaction. There is increasing research that suggests the routine use of interventions in childbirth may actually increase complications for mom and baby. Most of the time, these interventions can cause problems because they disrupt the normal physiology by interfering with hormones, creating opportunities for infection, and having unpleasant effects on your body and baby.

What things are most likely to lead to a cascade of birth interventions?

Labor Induction/Augmentation

Pitocin: The use of synthetic oxytocin (Pitocin), use of prostaglandin gel on the cervix (Dinoprostone), or a pill placed by the cervix (Misoprostol) are some of the most common ways to induce labor. These induction methods require monitoring in case you or your baby react unexpectedly. Fetal monitoring, contraction monitoring, and blood pressure checks are interventions added into the mix when you receive Pitocin. When the dose of Pitocin is increased too fast, it can fatigue the uterus and distress the baby. Pitocin can also make contractions harder to cope with. Forcing the uterus to contract with drugs means your body doesn’t provide a hormonal shift to help with pain management. Because of the contractions being more painful, most people will opt for an epidural.

AROM: Artificially breaking the water (AROM) is another way of inducing labor. It is usually used in combination with other methods. Once your water is broken, it is typical protocol that you must have the baby in 24 hours. There is no turning back once a provider breaks your water. If it wasn’t the right time to start labor and your body and baby are not ready, AROM is likely going to lead to many more interventions.

Starting labor when your body and baby are not ready has consequences. An induction is harder on the body and the baby, which often leads to pharmacological pain relief. 

Epidural Analgesia

An epidural is regional anesthetic that uses one or more pain medications. It is placed in the epidural space, which is right next to the spinal cord. It requires you to be monitored while staying in bed. Interventions for an epidural include blood pressure monitoring, a pulse oximeter, contraction monitor, fetal monitor, urinary catheter, and an IV.  Each of these can have a side effect of its own, but now you are essentially glued to your bed while you labor.

Laboring in Bed

Babies make a series of cardinal movements through the pelvis to be born. Active birth is easier on the mother’s body and helps the baby come down. A position might work for a while, but to keep helping the baby move down, you need to move your body to a different position. In active birth, you are more likely to know how to move to keep the baby moving. With an epidural your positions include, for the most part, turning from side to side. Baby’s heart rate may indicate distress, and if turning from side to side does not help, your provider may suggest a cesarean delivery. As for pushing, if you are unable to push productively on your back, a forceps or vacuum may be used.

Continuous EFM

Research has shown that electronic fetal monitoring (EFM) does not lead to better outcomes for mothers or babies. Instead, it actually increases some risks. Those who have continuous fetal monitoring are at much higher risk for cesarean sections and vacuum assisted births. “Non-reassuring fetal heart tones” is the second most common reason for primary cesareans in America. However, some high-risk women may benefit from continuous EFM like those that have preeclampsia or type 1 diabetes.

Some interventions are less likely to cause a cascade of interventions. That doesn’t mean they are safer, though. So then comes the question…

How can you avoid interventions in childbirth?

Avoid Induction: Most inductions are for convenience or for concern of being overdue. Babies are not considered late until 42 weeks. Prepare yourself to be pregnant until 42 weeks and find a provider who does not often induce before then.

Avoid Pain Medications: Take a birth class, hire a doula, and learn skills to manage the intensity of labor without drugs. The longer you can wait to get an epidural or other pain medication, the less likely there are to be more interventions.

Find the Right Provider: It’s necessary to find a doctor or midwife whose morals align with your own. Choose a provider who doesn’t use interventions without trying other methods first. A doula can also be a great addition to your team to help advocate for you and help you through the birthing process.

Unfortunately, it is impossible to predict exactly what may happen during childbirth. Educate yourself on the natural birth process so that you can feel in control. Have alternative ways to cope with your pain. Make sure that you are fully informed in your decisions. It is okay to question your provider on why they are recommending an intervention. This is your labor and birth so you are allowed to say no to an intervention that you do not want!