The Cascade Of Intervention – What You Need To Know

The Cascade Of Intervention – What You Need To Know

The majority of mothers hope for an uncomplicated, low risk birth – demonstrated by the fact that elective c-sections account for just 3-10% of births.

So we know that most mothers don’t plan to have a c-section.

Unfortunately, about 1 in 3 women in the US and Australia will give birth via c-section.

This is despite the fact that the World Health Organization recommends a c-section rate of just 10-15%.

In addition to c-section births, there are also many induced and augmented births, forceps and instrument assisted births, and other births that deviate from low-risk physiological birth.

Certainly there’s a time and a place for these birth interventions; they absolutely can and do save lives, but they aren’t without risk. Because of potential risks, it’s best to avoid these interventions whenever possible.

What Is The Cascade Of Intervention?

Sometimes, the reason we need these riskier birth interventions is because we have chosen a small intervention, which has led to a bigger intervention, which has then led to a riskier intervention.

This is known as the cascade of intervention.

When you choose even a small intervention and, as a direct result, another intervention becomes necessary, you’ve fallen into the cascade of intervention.

For example:

  1. You choose an IV pain medication to help cope with contractions.
  2. Due to the potential side effects of the medication, you’re now considered a fall risk, and you are limited to labouring in bed.
  3. Because you are less mobile, and can’t make use of gravity, your labour is slowed down, so you’re offered Pitocin/Syntocinon (artificial oxytocin, used to start or speed up labour).
  4. Due to the intensity of contractions augmented with artificial oxytocin, you opt for epidural pain relief.
  5. The epidural is quite effective, but now you’re unable to feel the urge to push after reaching full dilation. Pushing without the urge can prolong the pushing phase.
  6. After a while, you’ll either have an episiotomy, to make an instrument assisted birth possible or, if baby isn’t tolerating the intense artificial oxytocin contractions well, and is not yet close to birth, you’ll have a c-section.

What began as a low-risk, uncomplicated birth has become a heavily medicated and assisted birth.

It’s true that many women will have IV medications without side effects. Some will tolerate artificial oxytocin without an epidural, and some will have an uncomplicated and unassisted vaginal birth after the epidural.

However, the cascade of intervention is a real risk. It’s a risk women should be aware of when making decisions regarding intervention.

How Can One Intervention Lead To Another?

Birth is a normal physiological process, which involves the release of many different hormones.

Any time we interfere with this normal physiological process, we add risks.

As with all bodily processes, occasionally things might deviate from normal, and intervention becomes necessary. However, in the birth process, this is typically the exception and not the rule.

Most births, when properly facilitated in a safe environment, will unfold without complication or need for intervention. Rather than intervention remaining the exception, it has become the rule in many environments.

Each intervention, from one as simple as an IV with saline, to a major one, like a c-section, carries a risk. If a risk or side effect occurs, it often needs to be treated via another intervention. Occasionally, the second intervention leads to another side effect, and even more intervention, and so on.

Are The Risks Of Intervention Serious?

Sometimes an intervention has no side effects. Unfortunately, you won’t know whether or not you’ll experience side effects until after the fact. This is where you have to weigh up benefit against risk.

If an intervention is genuinely needed, or strongly desired, then you and your health care provider have most likely decided the known benefit of the intervention outweighs the possible risks.

If an intervention is not medically necessary, however, the benefit doesn’t always outweigh the possible risks.

Here are some possible side effects of common interventions:

  • Routine IV fluid can restrict movement, cause edema (swelling), and can lead to postnatal breastfeeding challenges. Read more in our article Routine IV Fluids During Labor – 4 Negative Side Effects.
  • IV pain medication can lead to restricted movement, feeling sedated, nausea and vomiting, respiratory depression, itchiness, and dizziness.
  • Pitocin/Syntocinon can lead to hypertonic uterus, postpartum haemorrhage, hypotension, and abnormal fetal and maternal heart rates, necessitating a c-section birth.
  • Epidural can cause hypotension, restricted movement, and prolonged labour, and increases the risk of instrument assisted birth. Read more about epidurals in our article Epidural During Labour – Everything You Need To Know
  • C-Section side effects include infection, haemorrhage, injury to pelvic organs, painful adhesions, and complications for future pregnancies (such as placenta accreta). You can read more in our article C-Section Risks For The Mother – What Are The Risks?

If there are potential side effects or risks, it doesn’t guarantee you will experience them, but it’s important to be aware of them in order to make an informed decision.

Smaller interventions, such as an IV, or a little artificial oxytocin, might seem relatively low risk. And in many cases they remain low risk interventions. However, once administered, they produce side effects in some women, and this can lead to further intervention and potentially very serious risks.

For this reason, it is important to be aware of the potential cascade of intervention when making decisions about birth.

How Can I Avoid The Cascade Of Intervention?

The decisions we make prenatally, as well as during labour, can have a great impact on how labour unfolds, and on its risk level.

Here are some things you can do to limit the risk of falling into the cascade of intervention:

  • Choose a low-risk maternity care provider, such as a midwife, with low rates of common interventions
  • Avoid elective inductions or augmentation of labour (‘elective' means there’s no clear medical need to start or speed up labour)
  • Utilise ongoing labour support – from a birth doula, for example
  • Talk with your maternity care provider about ways to reduce the risk of a procedure or intervention, if it becomes necessary or desired (e.g. turning down an epidural during the second stage, so you can feel the urge to push)

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Maria Pyanov CPD, CCE CONTRIBUTOR

Maria Silver Pyanov is a mama of four energetic boys and one unique little girl. She is also a doula and childbirth educator. She's an advocate for birth options, and adequate prenatal care and support. She believes in the importance of rebuilding the village so no parent feels unsupported.


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