Saturday, September 24, 2011

Cascade of Intervention in Childbirth

Source: Childbirth Connection

What is the "cascade of intervention?"

Many things in life have unintended effects: they may or may not have the effect that we want, and they may also have other unplanned and possibly unwanted effects.

Many maternity care interventions have unintended effects during labor and birth. Often these effects are new problems that are "solved" with further intervention, which may in turn create even more problems. This chain of events has been called the "cascade of intervention."

This chain of events can change the course of a woman's labor in important ways, yet women and their partners are often unaware that many routine interventions can lead to a cascade of unplanned experiences and unwanted side effects.

The maternity practices that can lead to a cascade of intervention include:

  • using various medications to induce labor
  • artificially breaking the membranes surrounding the baby and releasing amniotic fluid before or during labor
  • using synthetic oxytocin to hasten labor
  • giving medications for pain relief
  • using back-lying positions for labor or for birth.

In many instances, these practices cause problems because they disrupt the normal physiology of pregnancy, labor and birth — for example, by:

What is an example of the cascade of intervention?

Epidural analgesia can provide very effective pain relief during labor. It also increases the risk of experiencing a sudden drop in blood pressure, a longer labor, difficulty moving about, difficulty urinating, difficulty pushing the baby out, fever, and other undesirable effects.

A variety of interventions — such as continuous electronic fetal monitoring and intravenous fluids — are widely used with epidurals to monitor, prevent or treat these effects. And others become more likely, including use of synthetic oxytocin to strengthen contractions, use of a urinary catheter to empty the bladder, and use of a vacuum extractor or forceps to help move the baby out. These in turn may have side effects that lead to the use of other interventions.

The impacts can also extend to babies. For example, epidurals increase a woman’s likelihood of developing a fever; if a mother has a fever, caregivers worry that her baby may have an infection. Though few babies whose mothers have an epidural associated fever do in fact have an infection, as a precaution these babies often have blood tests and are treated with antibiotics just after birth. They may also be observed in a special nursery, which can interfere with bonding and breastfeeding.

This chain of possible effects from epidural and other interventions shows the importance of making careful, informed maternity decisions. 

How can I limit the problem of a cascade of intervention?

Almost every intervention has some potential to cause harm. You should make decisions about whether to have an intervention carefully. We encourage you to accept only those interventions that are more likely to offer benefit than harm. In weighing possible benefits and harms, it is important to rely on the best available evidence about potential effects, and to consider how you feel about the possible outcomes. It is also important to learn about other options that may be available.

Unfortunately, it is impossible to fully and accurately know in advance the course of a decision, and the degree to which other interventions and their effects will come into play. The best way to limit the problem of a cascade of intervention is to become informed, get all of your questions answered, set your goals and plans, and avoid interventions with the potential for harm, whenever possible.

The following may help you avoid unnecessary interventions:
  • choosing a maternity caregiver and a birth setting with low rates of using common interventions
  • becoming familiar with the best available research about interventions that are most likely to trigger a cascade of intervention, including induction of laborpain medications, and cesarean section
  • engaging in open and respectful dialogue with your caregivers about the rationale for every proposed intervention
  • exploring with your caregivers the options of watchful waiting (doing nothing, for the present at least) or using simpler, less invasive alternatives
  • learning about the benefits on continuous labor support, and consider engaging a doula to help you achieve your objectives
  • clearly communicating wishes to your caregivers, and getting the support of your partner, doula, or other companions
  • knowing that you have the right to accept or refuse procedures, drugs, tests and treatments, and to have your choices honored. 

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