Birth Pregnancy and Birth

The Cascade of Interventions and Why You Need to Avoid It

I learned about the cascade of interventions the hard way.

When I went into the labor with my second baby, I rushed to the hospital like any “good” mom would. They immediately strapped monitors on my belly and poked me with needles. They wouldn’t let me eat.

When the time came to push, they made me lie down in a position that was most convenient for the doctor (but awful for me) and he wound up cutting my vagina in a procedure known as an episiotomy to “help” the baby get out faster.

Thankfully I was able to avoid a C-section, but nevertheless, that birth was NOT something that I want to repeat.

Normally I don’t like to talk so negatively about birth. My birth experience was a bad one, but I believe with all of my heart that birth can be a beautiful and empowering thing.

I want to help you avoid experiencing what I went through, and have a birth that you can look back on with nothing but pride and joy over what you accomplished!

What is the cascade of interventions?

I first learned about the cascade of interventions when I was pregnant with my first baby and I watched a fantastic documentary called The Business of Being Born. If you’re pregnant or you think you might get pregnant or you know another human who might get pregnant, drop everything this moment and go watch it. It’s that important.

The jist of The Business of Being Born is that for many years our culture’s approach to birth has been to treat laboring women as if there is something wrong with them and take action (otherwise known as interventions) to “fix” them.

BUT, birth is a very normal, natural process. Pregnant and laboring women aren’t sick. Most women are completely capable of giving birth to healthy babies without the many interventions that are often done in hospitals today.

For example, many doctors don’t like women to be in labor for what they consider to be “too long.” In many hospitals, they place an arbitrary time limit, such as 12 hours, on a woman’s labor. If she hasn’t had the baby at that point, they’ll give her pitocin to speed things along.

That’s thoughtful of them, right? Those nice doctors just want to help you have your baby a little quicker.

The trouble with pitocin is that it makes contractions much stronger and more painful. Most women don’t last long on pitocin before they start asking for an epidural to get some relief from those intense contractions.

Again, this all sounds well and good. A little pain relief never hurt anyone, right?

But while the pitocin works to speed up your labor and contractions, the epidural is going to slow the whole process right back down again. So once the epidural is in place, they’re probably going to have to up your dose of pitocin.

Then you’ll start to feel the contractions again, and have to increase the medication you’re getting in the epidural.

Do you see the vicious cycle of these two interventions fighting each other?

Eventually, the pitocin may cause contractions that are TOO strong and send the baby into distress. At that point, its quite likely that your doctor will send you straight into to the OR for an emergency C-section to save the baby.

And that is the cascade of interventions. One intervention leading to another and another and another.

If you had an experience like that and didn’t know better, you might leave the hospital so grateful that the doctor was there to “save” your baby. But the reality is that if the doctor had left you alone and given your body more time to work it’s magic, the “saving” wouldn’t have been necessary at all. You could’ve had that baby just fine on your own.

Why the cascade of intervention is a thing

If the cascade of interventions is so bad, why does it happen so often?

Obstetricians are, first and foremost, surgeons. They go to school to learn how to do C-sections and how to practice medicine as it pertains to childbearing women. They learn surprisingly little about how birth is designed to work and what a woman is capable of in the process of giving life. They treat laboring women like they would any other sick person in a hospital: with drugs and surgeries.

The trouble is, women in labor are not sick! Birth is the only thing that happens in a hospital that is a normal physiological process. Everyone else goes to a hospital because they truly need help with some medical problem, so that’s how doctors and hospitals are designed to work. But laboring women, more often than not, don’t need any help at all, and should be allowed to labor naturally unless a true emergency arises.

Obstetricians also tend to be rather impatient. They don’t respect the amount of time that it can take to have a baby naturally. They want to get home for dinner or home or for bed or off to their annual holiday party. They generally want you out of their hair.

So when it starts to look like it’s going to take longer than 12 hours for your baby to come out, it’s all too easy for them to start suggesting a C-section because of your “failure to progress.”

Examples of interventions and their risks

There are lots of different types of interventions that can happen in a hospital. Way more than I can go into here or even have knowledge about. But here’s a few of the most common ones:

Pitocin

This is a drug administered through an IV to induce or speed up labor. It’s a great tool to have on hand when it’s medically necessary – like if you have preeclampsia or are starting to show signs of infection and the baby really needs to get out posthaste. Unfortunately, it’s used much more often than it should be. Some women even opt for inductions with pitocin for no other reason than they’re ready to be done with pregnancy!

Doctors and nurses will talk about Pitocin as if it’s no big deal, but it is definitely not without risks.

There is evidence to show that having pitocin can increase your risk of infection, increase your risk of uterine rupture, cause fetal distress and even death.

Better alternatives: If you’re having trouble getting labor going, there are lots of natural options to try before resorting to drugs like pitocin. Walking, movement, position changes are all great ideas. Using a breast pump is also known to jump-start contractions – you can ask for one in the hospital.

Continuous electronic fetal monitoring

When you go to the hospital to have a baby, one of the first things they will do is strap a device on to your belly to keep track of the baby’s heart beat while you’re in labor. At first glance, this seems harmless and perhaps even sounds like a good idea. Gotta make sure the baby is OK through this whole process!

Unfortunately, there’s zero evidence that continuous electronic fetal monitoring provides any benefit to mom or baby. In fact, it might actually cause more doctors to push for C-sections because of “non-reassuring heart tones.”

Better alternatives: You should ask your doctor or nurse if they can use intermittent auscultation instead. This is where the provider uses a doppler or stethoscope to listen to the baby every 15-30 minutes, and is not linked to a higher risk of C-section or other interventions.

Epidural

Most people are familiar with what an epidural is, and you might even be planning on getting one! Much like pitocin, doctors and nurses will talk about them as if they are no big deal, but there are risks involved with getting an epidural. Some of the milder side effects include itching and a headache that can last days. More serious risks include infection, seizures, and nerve damage.

An epidural can also make your labor last much longer and increase your chances of getting a C-section.

Better alternatives: There are lots of ways to manage the pain of labor without an epidural. I recommend taking a natural birth class such as Bradley, Hypnobirthing or Lamaze if you’d like to birth naturally. You’ll learn all sorts of comfort measures to help you cope with labor without the risks of an epidural!

Episiotomy

An episiotomy is when your provider makes an incision from your vagina down towards your bottom to make the opening larger and allow your baby to come out more easily.

The reason you want to avoid an episiotomy is because they can cause worse tearing than you would otherwise have. A more serious tear will be more difficult to heal from and can be more likely to get infected.

Better alternatives: Be upfront with your provider and let them know you want to avoid an episiotomy if at all possible. You should also find a provider who doesn’t perform them routinely. Do your pushing in an upright position instead of lying on your back!

IV fluids

The fact that having an IV is uncomfortable and restricts movement is reason enough to avoid it. If you receive IV fluids at a rate of less than 125 ml/hr you may wind up dehydrated, which can increase the length of your labor. However, if you get 250 ml/hr or more, it may cause swelling in both you and your baby. The swelling artificially inflates the baby’s birth weight, which may cause concern when they lose all of the extra water weight. It will appear that the baby is losing too much weight after birth which might impact your decision to continue breastfeeding.

Better alternatives: You’ll be better off getting your fluids and nutrition from eating and drinking than from an IV. Check with your provider to see if this is possible. If not, you may want to look for another provider or birth setting!

C-section

A C-section is the ultimate intervention that you want to avoid. The risks of C-section include infection, postpartum hemorrhage, blood clots, surgical injury, and more. One of the main reasons you might want to avoid a C-section is because of the impact it might have on future pregnancies. If you have a hospital birth for future pregnancies, you will no longer be considered “low risk” and you’ll be even more susceptible to receiving interventions that will in turn increase your chances of having a repeat C-section.

Better alternatives: The best thing you can do to avoid a C-section is to take care of your body throughout pregnancy and educate yourself about birth. Do your best to avoid any of the above interventions, as they often lead to C-sections. Sometimes a C-section is necessary for legitimate reasons, but they are performed far more often than necessary in this country.

You can say no to the cascade of interventions

So now you know some of the most common interventions and what the risks of each one are. That’s all well and good, but what should you do with this information? How can you avoid getting all of these interventions?

I encourage you to do further research about each type of intervention so that you are adequately prepared to make decisions in labor. The more educated you are, the more likely it is that you’ll be able to avoid interventions.

Remember that you can absolutely say no to any and all interventions that hospital staff may try to impose on you. No one is legally allowed to do anything to you without your consent!

PRO TIP: In a hospital setting, the words “I don’t consent to that” will get you a lot farther than simply saying “no.”

Unfortunately, there will probably be a lot of pressure in the moment to give in to this or that intervention. You’ll probably be told or given the impression that if you don’t consent, your baby could die.

It’s extremely hard to make those decisions and stand up for yourself in the moment with that kind of pressure.

Going through labor is one of the most challenging things you will ever do, the last thing you need is to be worrying about how to defend yourself against unnecessary intervention from doctors and hospital policies.

The difficulty of labor combined with the stress of being told that your baby will die if you don’t do something, means that you’ll probably wind up with lots of interventions if you don’t recruit some help!

That’s why I recommend that everyone who has a hospital birth also invest in a doula.

A doula can help you make informed choices and kind of be your brain for you when you’re in labor and it’s hard to think straight. She’ll also stay with you for the duration of your labor for support. You or your husband will still have to advocate for yourselves, but she’ll be there to support you and guide you.

The Best Way to Avoid the Cascade of Interventions

If you really want to avoid the cascade of interventions that can happen in hospitals, then one of the best things you can do for yourself is to avoid the hospital entirely!

After all, most hospital births are going to be attended by an obstetrician, and obstetricians are very medically minded when it comes to birth. They simply aren’t trained to respect the natural birthing process. In light of that, it’s in your best interest to find a provider and setting that will allow you the space that you need to get your baby out naturally.

Avoiding the hospital might seem extreme to you. After all, probably almost everyone that you know has had their babies in a hospital setting. Is it really safe to give birth anywhere else?

The answer, of course, is a resounding yes! You basically have 3 options if you don’t want to give birth in the hospital:

  • Birth center – Birth centers are an awesome choice for women who want to stay out of the hospital. Most birthing centers are staffed by naturally-minded midwives and nurses. You’ll often find that the rooms are set up to be much more home-like than a hospital room. There might be a queen bed instead of a delivery table and you’ll probably find a birthing tub in each room. You’ll probably be allowed to eat and drink throughout labor, and you’ll be monitored by intermittent auscultation instead of continuous electronic fetal monitoring. Some birthing centers are even located within hospitals for extra peace of mind if you feel nervous about being away from the hospital setting!
  • Home birth – a home birth is also a fantastic option for birth that is often overlooked by many women. Many people think of home birth as being too dangerous, but it’s actually quite safe as long as a few conditions are met:
    • You should find a qualified, reputable midwife to attend your birth. This can be tricky, but I recommend asking around to see if anyone you know has had a home birth and ask for a recommendation from them. You can also search Facebook for “home birth” + “your city” to find a group dedicated to home birth in your area that can provide assistance.
    • Your pregnancy should be low-risk.
    • You should have back-up care from a provider with hospital admitting privileges willing to oversee your care and admit you to the hospital in case a hospital transfer is necessary.
  • Unassisted birth – Also called free birth, this is where a woman chooses to give birth at home without any assistance from a doctor, midwife, or even a doula. I do NOT recommend this option. There are simply too many risks involved, but some women choose to do it anyway for a variety of reasons.

So those are the options available to you if you want to stay out of the hospital!

It is possible to have a natural birth without intervention in a hospital setting, but you’ll need to do some serious preparation and be ready to hold your ground and stand up for yourself under difficult circumstances.

In my opinion, it’s so much easier to give birth in a setting where I know I won’t feel like I’m fighting a battle while also trying to give birth to a baby.

That’s why I’m choosing a home birth for my third baby!

I’m excited about this birth because I know I’ll have a team that totally supports my philosophy of birth, and they won’t be forcing any interventions on me unless it’s truly an emergency and there are no other options.

But obviously you have to decide what’s best for you!

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