The Cascade of Intervention – What is it??

Many maternity care interventions (induction) have unintended effects during labour and birth. Often these effects are new problems that are “solved” with further intervention, which may in turn create even more problems. This idea that using one intervention can lead to the need for more interventions is called a “cascade of intervention.”

Often when one embarks on agreeing to the first method of induction, it leads to a sequence of further interventions resulting in either a c-section or a very physically tiring and demanding vaginal birth with the use of instruments such as ventouse or forceps (see end for information on instrumental birth).

The maternity practices that can lead to a cascade of intervention include:

• Using various medications to induce labour such as a sweep
• Artificially breaking the membranes (a sweep) surrounding the baby and releasing amniotic fluid before or during labour.
• Using synthetic oxytocin medicine (“Pitocin”) to make labour move faster.
• Giving medications for pain relief.
• Labouring in bed versus being upright and moving about.

In many instances, these practices cause problems because they disrupt the normal physiology of pregnancy, labour and birth by:

• Interfering with hormones that move labour and birth along.
• Creating opportunities for infection.
• Having undesirable effects on your baby.
• Making it harder for you to push your baby out.

When these effects happen, women may feel that their bodies have failed them, not realising that the things that went wrong could have actually been triggered by maternity practices themselves, not the inability of your body – it is very rarely that!

Unfortunately, it is impossible to predict in advance exactly what may happen during your labour and delivery, or how a given intervention may affect you or your baby. The best way to limit a cascade of intervention is to become informed, get all of your questions answered, and put plans in place in advance that will help avoid potentially harmful interventions.

Here are some tips for avoiding unnecessary interventions:

• Choose a care provider and a birth setting that have low rates of using common interventions.
• Get a doula who will advocate for you
• Ensure your birth partner understands and supports your birth choices and can also advocate for you
• Become familiar with the best available research about interventions that are most likely to trigger a cascade of intervention, including induction of labour, epidural analgesia and other pain medications and caesarean section.
• Have an open and respectful conversation with your care provider about why you need any recommended interventions. It’s ideal to have this conversation well before you may need the intervention so you can express your wishes and discuss plans.
• Talk to your care provider about options like “watchful waiting” (doing nothing and waiting for labour to move along or for issues to resolve on their own) or using simpler, less invasive alternatives.
• Learn about the benefits of continuous labour support ie with a doula
• Clearly communicate your wishes to your care providers, and get the support of your spouse, partner, doula or other companions to reinforce your wishes throughout labour and delivery.
• Be aware of care providers own fear and stand strong in your knowledge rather than getting into their story. Share facts and information to support your choices
• Know your birth rights
• Know that you have the right to accept or refuse procedures, drugs, tests and treatments, and to have your choices honoured.

The Cascade of Intervention in Action

Epidural is a good example of the cascade of intervention. It can provide very effective pain relief during labour, but it also increases the risk of experiencing a sudden drop in blood pressure, a longer labour, difficulty moving about, difficulty urinating, difficulty pushing the baby out, fever and other negative effects.

Interventions like electronic foetal monitoring and intravenous fluids are often used with epidurals to monitor, prevent or treat these effects. And others become more likely (synthetic oxytocin to strengthen contractions, catheter to empty the bladder, vacuum extractor (ventouse) or forceps to help move the baby out). These in turn may have side effects that lead to the use of yet more interventions.

Babies can also be affected. For example, epidurals increase a woman’s likelihood of developing a fever, which can make doctors worry that the baby has a fever. This leads to blood tests and antibiotics for the baby after birth. They may also be observed in a special nursery, which can interfere with mother-baby bonding and breastfeeding.

Additional suggested resources

BOOK – ‘In your own time’ by Sara Wickham

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