CASCADE OF INTERVENTIONS
Maintain a lower risk profile by choosing interventions carefully
Stop the Domino Effect or Cascade of Interventions in Labor
The Cascade of Interventions
The Domino Effect or the Cascade may come in many forms. It could start with an intervention that may not even seem significant at first glance, like leaving your home or getting a cervical exam, but these are two very important points in labor, out of many, to plan for and to navigate carefully if your goals are to reduce interventions and increase comfort.
The core foundation of comfort in labor is to know that anything that can disrupt the physiological process can create pain. A disruption of blood flow to the uterus can send an otherwise healthy baby into distress. The hormonal disruption may also create pain, as the hormones of a natural birth can be as powerful as morphine. We want to encourage those hormones to build up to their full potential. We want to prepare our mind so that we are filled with confidence in our birthing body and can focus on turning inward and create an environment where we can easily release tension, breathe slowly and relax our deeply. We need to have an acute awareness of the fetal positioning preparation and implementation for maximum comfort and progress. We want to nourish our body and therefore our uterus, placenta and baby with the energy they need to work well.
We can apply all of these principles to help us navigate the process of birth, even when plans change. Some choices we make from the beginning can help set us up for a more smooth and fluid process, much like a mountain climber will carefully choose a high quality guide, we need to choose a care provider and doula who will take us on the path with the least risky terrain. The sherpa who knows every nook and cranny will be the most valuable companion.
Decision Making in Labor
Once decisions have been made, those choices may lead to other complications, which will then need to be navigated. Avoiding the first intervention may stop the cascade before it begins. There are ways to mitigate risk. If an induction is absolutely medically indicated, then choosing medication that has a lower risk profile, using a lower dose and combining it with natural methods may all work together to prevent the cascade as well. Having doula support and a care provider with low rates of intervention will also help increase your chances of having a natural birth. The choices you make matter.
Doulas are associated with statistically shorter, safer births and labors that are more comfortable.
Continuous Labor and Delivery Support
Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery. Given that there are no associated measurable harms, this resource is probably underutilized.
Care providers with low cesarean rates most likely have these low rates because they understand how to support the physiological process.
They may also have an understanding of optimal fetal positioning and know how to help your baby move through your body more easily. Care providers who have low rates of intervention and better outcomes will often practice Expectant Management. This may protect a mother from interventions. In this model of care, the care provider will not routinely intervene. They will watch the mother carefully and only intervene if there is a medical need.
In contrast, Active Management is practiced by care providers who will intervene according to a set time frame. This model for management of labor in the United States is a distorted version of a clinical trial that was implemented at The National Maternity Hospital in Dublin. In this clinical trial women were assigned to one of two groups. One group was the standard of care at the time, while the second group received:
1. Early amniotomy/artificial rupture of membranes (AROM)
2. High-dose pitocin
3. They were only admitted if had reached effacement of at least 80 percent, bloody show (not precipitated by vaginal examination), or spontaneous rupture of the membranes
4. They had customized childbirth classes
5. They received one-to-one care for the duration of labor
6. They had the assistance of nurse midwives
This approach was adopted by many U.S. obstetricians, but without the strict criteria for admission, the one-to-one care, the customized childbirth classes or the nurse midwife, yet the early amniotomy and use of pitocin augmentation were implemented. Many obstetricians take this clinical trial as a template and implement it selectively. For example, they will give routine vaginal examinations every 1-2 hours and intervene with pitocin or other interventions if no change is detected.
Many women would benefit tremendously from effects of numbers 3-6, but unfortunately many obstetricians overlook the most beneficial aspects of the study and only the interventions listed in numbers 1 & 2 are imposed on laboring women.
ACOG Recommends Change
Recently ACOG has recommended re-evaluating many of their clinical practices, such as time limits in labor. They now advocate for 6cm as the official start to active labor. They also recognize that women may labor longer safely and have moved farther away from strict time limits in labor:
The difficulty is that ACOG is still light years away from recognizing how hormones, blood flow, physical tension, the mind-body connection, and the labor environment might impact the process. They also have an entrenched system that moves changes through at a painfully slow pace:
Changing the local culture and attitudes of obstetric care providers regarding the issues involved in cesarean delivery reduction also will be challenging.
This information may help a mother decide what type of care provider she prefers to work with and what type of care she feels is best for her. She can ask a care provider what type of management model they follow and she can ask them to describe what that means and looks like to them in it's implementation.
When interventions are offered, the laboring mom may or may not want to access them, depending on her own personal needs and concerns. Not every intervention that is offered will be right for every mom. It may help to simulate the "trail" of labor before the real journey begins: