Health

How The Cascade of Interventions Interferes With Childbirth

This piece was co-written by the founders of Wildish, a women’s wellness company that makes plant-based products to support healthy fertility, pregnancy and postpartum. Learn more at: www.wildish.co

This post is tailored for women who are interested in having a childbirth that minimizes intervention, otherwise known as a more natural childbirth. When we say intervention we mean any activity on the part of the caregiver that intervenes with the childbirth process with the goal of helping it along. This could include fetal monitoring, intravenous fluids, labor induction, epidurals, episiotomies, and of course, cesarean delivery, among other things.

If you’re interested in learning more about the factors that contribute to natural childbirth and a birthing experience built around supporting the body’s natural physiology, then this is for you.

Healthcare professionals get up every day with the goal of making people better and they work tirelessly to do so. Unfortunately, the healthcare system they operate within incentivizes them for doing more, not less. In a certain sense, the more interventions (medications, procedures, monitoring, restrictions, etc.), the more money is made by all of the entities that make up our healthcare system.

This is especially problematic for women in labor, because in most cases, women are not “sick” when they arrive at the hospital to give birth. They are undergoing a natural physiological process.

The United States operates under an intervention intensive model for maternal care, meaning that when a woman is in labor, the tendency is to recommend more and more interventions to keep the delivery moving along.

Childbirth is governed by a complex orchestration of hormones that is easily disturbed. Once the body’s physiological process is interrupted, it creates the need for more and more interventions to keep it moving along. This phenomenon is known as the Cascade of Interventions.

Research shows that all of the interventions during labor disturb the natural physiology of birth while making it harder for women to cope with the natural challenges of labor. According to an article and meta-analysis on this topic, published in The Journal of Perinatal Education:

The high use of these interventions reflects a system-wide maternity care philosophy of expecting trouble. There is an increasing body of research that suggests that the routine use of each of these interventions, rather than decreasing the risk of trouble in labor and birth, actually increases complications for both women and their babies

Let’s look at one example of how this can play-out. We’ll start with something as simple as a woman being hooked up to continuous Electronic Fetal Monitoring (EFM), something that occurs in 66% of deliveries according to the Listening to Mothers III Survey.

EFM was introduced in the 1970’s as a way to decrease cerebral palsy and perinatal mortality. Although no evidence supports its effectiveness, it remains common practice.

In a review of 13 randomized controlled trials, spanning 37,715 women by Alfirevic, Devane, and Gyte (2013) found that women who were monitored continuously with EFM were more likely to have a cesarean surgery or instrumental vaginal birth.

Why? The answer is three-fold:

  1. Restricted Movement: EFM wires restrict the woman’s movement and require that she give birth lying down or in a semi-sitting position. This limits the ability for gravity to support the decent of the baby through the birth canal as well as for the woman to move her body to initiate delivery, often necessitating additional interventions to speed up labor.
  2. Increased Stressors: the sounds and displays on the monitors are a distraction to the laboring woman, take attention away from her needs, can increase stress levels and limit access to comforts that assist with normal delivery.
  3. False Positives: It increases the likelihood of seeing abnormal fetal heart rate patterns that pose no risk. The majority of these heart tones are caused either by normal physiological processes (like contractions) or are the result of yet further interventions like Pitocin wearing off or giving the woman other drugs, but they do not indicate the need for a Cesarean. 23% of all Cesareans are the result of these false positives, second only to Failure to Progress (34%).

According to research by Goer and Romano 2012,

EFM increases interventions without improving neonatal outcomes. EFM disrupts normal physiology of labor by restricting movement and potentially interfering with appropriate labor support as providers and family watch the monitor. It certainly limits women’s access to comfort measures such as showers, tubs, and birth balls and that ultimately can increase the chance that they will need an epidural and a further cascade of interventions.

This all may sound rather overwhelming, but there’s a number of actions to consider if you’re looking to have a more natural childbirth. Here’s seven practices that help to facilitate the natural physiological process and therefore reduce the necessity for unexpected intervention.

  • Find the Right Venue: consider whether delivering in a birth center or at home staffed by certified nurse or homebirth midwives is right for you. These individuals and practices place high importance on the well-being of the woman and facilitating the natural process of childbirth.
  • Right of Refusal: know that you have the right to refuse any treatments, medication, procedures or monitoring. You are the patient and, legally speaking, everyone answers to you.
  • Labor Induction: letting labor start on its own, rather than inducing, ensures both mother and child are ready from a physiological standpoint. Induction is often the first event in the cascade of interventions. Ask your doctor for their opinion and how long they’re willing to let you go past your due date before recommending induction.
  • Freedom of Movement: Allowing women to move around freely versus limiting them to lying down helps them to better cope with pain, protects the birth canal and supports rotation and descent of the baby, speeding up labor.
  • Advocacy & Support: Having emotional support during labor decreases fear, provides avenues for physical relaxation, and ensures privacy, which positively impacts the natural hormonal process in ways that we’re just starting to understand. Having the right person(s) present to support you is key.
  • Skin-on-Skin Time: Keeping mother and baby together immediately after birth for breastfeeding, bonding, and microbiome development has a tremendous emotional and physiological impact on both parties.
  • Additional Research: consider exploring the research behind some of the more common interventions including: using medications to induce labor, artificially breaking the membrane to induce labor, using synthetic oxytocin to move labor along, medications for pain relief, and laboring in bed versus moving around.

This should all seem pretty intuitive but it’s staggering how often these evidence-based best practices are ignored. These findings are summarized in Healthy Birth Practice papers by Amis (2014), Crenshaw (2014), DiFranco and Curl (2014), Green and Hotelling (2014), and Ondeck (2014).

Child birth is a natural process that women have been undergoing successfully for thousands of years. But, it is also a delicate one, governed by hormonal interactions that we’re just beginning to understand. As a result, it can be easily disrupted. If birth that prioritizes the body’s natural physiological process is a priority, then intervention of any kind should be approached with care.

Conversation with your caregivers and support systems to articulate your wishes and to understand how they can assist is likely the first and most important step towards ensuring you have an empowering birth experience.

This piece was co-written by the founders of Wildish, a women’s wellness company that makes plant-based products to support healthy fertility, pregnancy and postpartum. Learn more at: www.wildish.co


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