You’ve heard the term cascade of interventions, and you’re worried about your plans for a beautiful vaginal birth escalating to a surgical birth. You may still be trying to decide if it is worth it to go au natural – without epidural pain relief or if the epidural is worth the risks. Or you might be trying to decide if you want to induce your labor and meet your baby now, instead of when they decide.
When it comes to birth, there are a lot of options. We are here to help you navigate the information and make informed and centered decisions.
Let’s chat and help you find your answer.
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What Is The Cascade Of Interventions?
Medical care in birth can be tricky – while for one mom, a simple IV, epidural and Pitocin could help her have a safe and happy birth. For another mom, the same simple interventions could contribute to unnatural contractions, fetal distress and ultimately abandoning hope for a safe vaginal delivery and needing to opt for a surgical birth instead.
The term ‘cascade of interventions’ refers to the chain reaction of medical procedures during labor. The idea being, once one intervention has been started, others will be needed. Interventions are sometimes necessary. The concern is that when they are used routinely, with no medical indication, they can disrupt the natural birthing process.
When we are talking about the cascade of interventions, we are talking about the unnecessary use of minor or major medical interventions that lead to the need for more interventions. Ultimately, putting a mom or baby at risk. While these interventions can be small, such as an IV with a bag of fluids, more commonly, they are associated with epidurals and elective inductions.
Let’s Look At An Example Of The Cascade Of Interventions:
A first time, low risk mom begins experiencing contractions at home. Her labor has been picking up. She is noticing her contractions getting longer, stronger and closer together, and as she is timing contractions she recognizes it is time to go to the hospital!
There is a sense of peace and excitement in this moment. She works hard on focusing on her breath and moves to the car, while her partner loads all their things.
They drive to the hospital, go to triage and are admitted. The first step on admittance is getting an IV and a routine bag of fluid. The nurse says, “We just don’t want you to get dehydrated. It’s nothing to worry about.”
Intervention One Just Happened – The Bag Of Fluid. Did You Catch It?
It seems like a great idea to not get dehydrated, and it’s just fluids anyways. So she agrees.
Shortly after, she notices her contractions aren’t as close together and labor seems to be getting slightly easier. That seems great at first! Until her doctor points out that she hasn’t made any change since getting to the hospital. How is it possible that she has been here laboring like this for four hours and is still at 4 cm dilated?
The routine bag of fluid actually did have a risk that was never talked about or disclosed. In adding an unnatural amount of fluid to her system, the natural hormones coursing through her body causing her contractions became diluted – resulting in fewer and less strong contractions, also resulting in no dilation.
Though the contractions are no longer as strong as they were, they have still been a lot to work through. This news brings her to a new emotional low. Can she really do this? The doubt is now planted firmly in her mind.
And with good reason, a slow labor, with contractions spaced out is hard to get through. And will she ever get enough power back in her labor if those fluids continue? No one knows. So it’s time for the next step,
Intervention Two – The One That Wouldn’t Have Been Needed Before Intervention One Was Given
The doctor suggests that they add a new drug to the IV – a drip of Pitocin.
“It’s exactly the same hormone as the natural Oxytocin your body is already making,” they assure her. It’s nothing to worry about.
Again, a benefit given, without a clear conversation about the risks, which are too plentiful to disclose in this article or in one conversation during labor. And truly, with spaced out contractions like this, options are limited, intervention is likely needed.
The drug is started. Contractions do get stronger, and more painful. Too painful. She’s shaking, overwhelmed and asks for an epidural.
After the epidural, she can no longer move around, she no longer has the benefits of movement and gravity to help the baby navigate through the pelvis. Contractions space out again, so the Pitocin drip is increased, using more medication to keep her labor going. Everything is starting to feel so overwhelming – that is until things get even worse.
As the Pitocin keeps being turned up again and again, to solve for the contractions being pushed farther apart by intervention after intervention, the baby’s heart rate begins to show dips. The heart rate decelerations start small, but the heart rate shows more and more signs that the baby is in trouble. Her baby is not tolerating labor very well anymore.
The Escalation – It’s Time To Save You From Danger And Save Your Baby
Eventually, the doctor comes back into the room and states, “I’m sorry, but your baby needs to be delivered now. It’s time for surgery.”
The mom doesn’t understand how she went from low risk, to a baby in distress. Birth feels wildly unsafe at this point. But, she will do anything to protect her baby. Thank God she is at the hospital where they can help. So she goes back for surgery.
Was the surgical birth needed at this point? Likely yes, her baby was in distress and that can’t be ignored.
Would it have been needed if that routine bag of fluid was never given to “prevent” dehydration and a water bottle had been handed to her instead? Possibly – but likely not. This moment was a turning point that potentially started a cascade of interventions.
In this story, the need for a surgical birth was created by a series of events that was started with a minor and seemingly insignificant intervention. This is the cascade of interventions – and when we look at data, you may see it is more common that most think.
However, though the path was not the one they planned on -they did end up with a healthy mom and healthy baby. Full recovery and joy was still an important part of their story.
The Listening Mother’s Survey Reveals How Common The Cascade Of Interventions Really Is
The most common interventions in labor are epidurals and inductions. Luckily, we have some information on what happens in first time moms who choose or are pressured into these interventions. And when I say that, I mean it honestly. Some moms choose inductions and epidurals from a place of self awareness and desire – wanting those tools as part of their birth. And those choices should be honored and respected.
On the other hand, sometimes moms are pressured into them. Adding to the feeling of chaos, lack of control and uncertainty in their birthing process.
This data comes from the 2018 Listening Mother’s Survey. Which is a survey of what actually happened in births that took place in the state of California.
What Was The C-Section Rate For Moms Who Chose No Interventions?
Moms who chose no interventions, who opted to let labor start on it’s own and used internal tools to manage the waves of contractions, had the lowest c-section rates. While it may seem a bit hippie to say “the body knows how to give birth” we can clearly see that when birth is not intervened with, things do go predictably very well.
A 1% c-section rate for these moms is quite remarkable. And the amazing thing is that these results have held up over time as well. In 2013, the surgical birth rate for these moms was 5%.
Moms who are trusting their body to start labor on its own and are opting out of an epidural definitely have a VERY HIGH probability of getting their healthy mom, healthy baby + vaginal birth outcome.
What Was The C-Section Rate For Moms Who Chose Either Induction Or Epidural?
What happens when moms choose just one of the larger interventions to their labor? Well, the number of moms needing a surgical birth definitely goes up. You can see that the c-section rates jump from 1% to almost 20% when moms either induce or use an epidural, but not both.
The display above shows an 18% surgical birth rate. It looks very different than a 1% birth rate, doesn’t it?
Again, this is very similar to the trend in 2013. We can see the cascade of intervention story is both real, and has held up over time.
What Was The C-Section Rate For Moms Who Chose Both Induction And Epidural?
When moms choose both an induction and an epidural, which almost always do go hand in hand anyways, the c-section rate takes another giant leap to 30%. So you can see that when moms trust their body and move through contractions on their own, the birth process is quite predictable. But, the more interventions stack up, the more a mother and her care team are juggling and the more likely something will drop, resulting in a needed surgical birth.
From this data, it is not hard to conclude that a significant number of surgical births could be prevented if we had fewer inductions and fewer epidurals.
For that to be possible, moms need to know how to manage contractions and how to communicate with their care team in ways that allows them to confidently accept treatment if it is necessary, and confidently trust their body in the birthing process when the body is expertly laboring. The labor process is a delicate dance that is best not interfered with in most cases.
We teach moms how to handle contractions like a pro in our birth class! If you are preparing for birth and want to go epidural free, we have everything you need!
But, if you find yourself wanting an epidural even knowing the risks or needing or wanting an induction, we’ve got you covered too.
We know the same tools that help moms in an epidural free childbirth don’t always translate to an epidural birth. Inside our class, we’ve got an epidural track that will help you stay proactive and prevent many of the obstacles that happen with an epidural as well.
So, if you’re looking to improve outcomes – make sure to join us in our childbirth class.
Why Can Natural Labors Sometimes Be Easier Than Medical Births?
I often hear moms who have taken an epidural route in their birth say “wow, if this is so hard with the epidural, I can’t imagine how hard it would be to do it naturally.” But the truth is, as a doula that has been with hundreds of women giving birth, I think that the medical birth, the birth that starts with an induction and includes an epidural, is often more grueling, tiring and emotional than the natural birth.
Why is that?
Well, have you ever seen a Chinese Plate Spinner? You know that act where someone spins a plate and balances it on top of a long and skinny pole? Well, if you consider a natural birth, a mom has one plate to balance. Her main focus is working through contractions. She can generally trust that her body will make the right amount of contractions in the right frequency to bring her baby to her without either of them going into a medical emergency.
What Else Is The Induction + Epidural Mom Spinning On Top Of Pain Management?
A mom that has taken a more medicalized birth route has more to spin. Is her pain being managed appropriately? What are all these wires and attachments now that you have an epidural? Are the contractions strong enough and close enough that they can get you through to birth? Is baby handling the medications ok? And is mom handling the medications ok?
She has many more plates spinning and many more uncertainties than the natural mom. This often leads to less physical intensity, but much more mental, emotional and medical intensity in the experience.
Ultimately, deciding between a natural birth and a more medicalized birth is a very personal decision. One that can be right now matter which choice you make. However, in general, I think many moms over estimate the difficulty of handling contractions and underestimate the difficulty of handling all those other spinning plates.
When it comes to preparing for birth – preparation matters quite a bit. Epidural or not.
Let’s Explore The Cascade Of Interventions Through Real Birth Stories!
A Mom Protecting Her Natural Birth
I was recently at the hospital with a mom who did not want an epidural, and who had waited for labor to start on its own. When we arrived at the hospital, her contractions were out in full force. She was moving, breathing, doing all the things she could to cope. And she was doing great.
While I filled the tub, the nurse made a simple offer. “Your contractions are so close together and strong, can I give you an IV to make this easier for you? Space out your contractions a bit?”
The mom didn’t need me to make her decision. She simply said no thank you, grabbed a sip from her water bottle, and continued on.
It was only three hours later that she had her baby in her arms. Later she asked me why the nurse wanted to slow down her labor. I truly didn’t have an answer, other than the nurse must not have been around enough non-epidural births to know that she was so close to the end yet.
This mom did a great job of protecting her natural birth, trusting her body and moving through contractions until she met her perfect little baby.
Choosing A Medical Birth Because You Want It
On the other hand, I had another mom I worked with who had a baby due just around the Christmas Holiday. When we got together to discuss her birth plan at her prenatal, she told me: “I only have one goal, I want this baby before Christmas.” She knew she wanted an epidural, and was up for an induction.
We talked through the process so she had a good understanding of what inductions can be like. We made a plan for a quick induction or a 3 day induction. Both time frames are reasonable for an induction – and nobody knows when an induction starts if they’re in for a long birth or a short one.
We also went through a few ways to make inductions easier, which you can find here.
And, we talked through our epidural best practices from the childbirth class.
Ultimately, she went in for her induction and had her baby in her arms 24 hours later. She also had a healthy vaginal birth.
Why Is This Important?
Is the cascade of interventions real? Yes. But can you make a good decision to move forward with epidurals and inductions anyways? Sure. Especially if you can come to peace with the process and are proactive through it.
Not every birth that has medical intervention is going to result in a surgical birth, and we don’t want to give that impression.
The important thing is that you were educated, you had quality information on what to expect and you are able to make shared decisions with your care provider through the process. Just like this mom did!
This mom also did a great job making decisions that reflected her values and needs. And also had a perfect little baby to snuggle up with after labor.
Choosing A Medical Birth Because You Need It
Sometimes the hardest place to be is in the ‘choosing a medical birth because you need it’ category. Last winter, I worked with a family where the mother had sustained a fall on the ice. After the fall, she went in to the hospital to check on baby. Everything seemed okay. We all breathed a sigh of relief and she returned home.
However, several weeks later, she noticed that her baby’s movements weren’t quite the same. She went back to the hospital, hoping for reassurance everything was fine. Instead, she was told the baby looked ok, but that there were some concerns about baby’s heart rate that hadn’t been there before.
Mom’s intuition was spot on – even if it wasn’t the news she wanted to hear.
She was ultimately given the decisions to stay or go, but with the advice that they all hoped she would stay to be induced. Which she chose to do.
How Did Her Labor Go?
Her labor was long and slow. It took a full three days to meet her baby.
She was offered many different tools at different times to help move her labor along. Some which she agreed to and some which she declined. Some which she was happy she did and some she wished she had declined.
But, every choice felt like it weighed a thousand pounds. Her partner told me that his friend had said “when you get to the hospital, you really have to stick up for your wife, they are going to try to intervene and speed things up at every step of the way. Don’t let them do it.”
But now, they weren’t in a place of labor starting on its own. They were in a place where they needed tools to move things forwards to keep their baby safe. The situation life gave them put them between two ideological places.
They valued labor starting on its own, and didn’t want interventions. But, they were worried something would happen if they went home, and wanted labor to start. Meaning they did need to use interventions they otherwise would have said no to.
It was tricky, but they also ultimately found their way to a healthy mom, healthy baby and vaginal birth.
I wanted to share this story because sometimes knowing the cascade of interventions is real makes us think we should always decline interventions. But sometimes, we have the right reasons to use them. Or we just want to use them. And in those cases we should.
Why Do These Stories Matter?
My goal with this post is to help you have confidence in asking for interventions when they are needed, and declining when they aren’t. To give you tools to advocate for your preferences in the how to arrive at a safe and healthy delivery.
Some moms intrinsically know a natural labor is best for them. Others intrinsically know epidurals are best for them. Others make decisions to meet needs as they evolve. All of these moms are choosing the best path.
For those considering interventions, but nervous about them I have a great resource. There is a great podcast interview with Baby Lawyer Gina Mundy and Doula Brandy Jordan on the Dear Doula Podcast. I highly recommend giving it a listen to moms who feel as if they are stuck in the middle of not wanting interventions, but no longer fitting into the low risk category.
One thing she points out is that sometimes too little intervention can be just as dangerous or more as too much intervention.
We all need to find the sweet spot for our individual families and needs.
Is The Cascade Of Interventions Real? TLDR
Exploring the cascade of interventions question can feel a bit overwhelming. Some moms will look at this and intuitively know that they are ready and they can pursue a natural birth. I truly believe that every mom that prepares for a natural labor and sets her mind to it, can do it!
We see moms go through our childbirth course and be successful navigating natural births all the time!
That said, epidurals and inductions can also be the right choice.
We know that there are simple things epidural moms can do to make their experience better and safer for both themselves and their little ones. We’d hope you’d join us in our childbirth class, especially if you are using an epidural.
And what if you do have a surgery, even after all you careful preparation?
As a mom that has two daughters, one from a surgical birth and one from a vaginal birth – I can attest that both ways of giving birth have their reasons and benefits. More importantly, both ways to give birth are a beautiful rite of passage and journey into motherhood.
It may take a lot of work to get a tiny human out of your body. But, I can assure you that you are strong, capable and can do this! Welcome to motherhood and thank you for bringing a beautiful new life into the world!
