How to Avoid a “Cascade of Interventions”

Dr. Nicole Calloway Rankins:

On balance, when you’re in the hospital, we tend to do things or offer things so you’re more likely to have things happen when you’re in the hospital. Now, a lot of that depends on the hospital and the culture of the hospital, but in general, stay home as long as you can, because once you get to the hospital there’s gonna be more temptation for interventions. 

Adriana Lozada: That’s OB/GYN, Dr. Nicole Calloway Rankins, talking about one way to minimize the cascade of interventions, which is the idea that an initial intervention during labor can create the need or desire for another intervention, and as these interventions snowball or cascade from one to another, they may create problems and narrow your options or increase the risk of having a cesarean birth. Most interventions impact your birth hormones, and some may improve one aspect of labor while at the same time creating opportunities for infections or having undesirable effects on baby. They may even make it harder to push your baby out. 

So, Nicole and I will be talking about some of the most common medical procedures that can be part of a cascade of interventions. 

I’m Adriana Lozada and you’re listening to Birthful, here to inform your intuition. 

Hi, Nicole. It’s so great to finally have you here on the show. And before we get to it, why don’t you tell us a little bit about yourself and how you identify? 

Rankins: Sure. I am Nicole Calloway Rankins. I’m a board certified OB/GYN. I have been in practice for almost 15 years. I cannot believe that. And I work as an OB hospitalist, meaning I work only in the hospital. I do shift work, where I work 24-hour shifts at a time and have the privilege of caring for whoever comes during my shift, and I also have a podcast and an online childbirth education class, and I identify as she/her. 

Lozada: And tell everybody what the name of your podcast is. 

Rankins: Oh, yes. It’s called All About Pregnancy and Birth. 

Lozada: Excellent. It’s a wonderful podcast. I love it, as well. 

Rankins: Thank you.  

Lozada: And that laborist model or hospitalist model is a very unique one and so, basically people don’t decide you’re gonna be their OB and do the whole care with you. It’s more that they have their own group, they have their own doctors, but when they get to the hospital, you are the person, if you’re on shift, you’re the one that will deliver the baby if they give birth during that time. 

Rankins: Yes. Yeah. Yeah, so I meet people just during labor for the first time. 

Lozada: And how is that experience? 

Rankins: I love it. I absolutely love my job. The birth never gets old or it never loses its excitement and thrill, so it does present some challenges in that I have to very quickly establish that trust and rapport and things like that, but I love it. 

Lozada: So, I wanted us to talk today about the cascade of interventions, and people might have run into that term in their Google search, or in the books they’re reading, and I really wanted to get deeper into because I think usually it’s talked about very superficially. So, what is the cascade of interventions? 

Rankins: I think about it a couple of ways, like if you want a low-intervention birth, essentially it means starting to intervene, so that can mean things with like Pitocin in particular or breaking your water. Those are the two biggest things that I think will trigger things that start that cascade, and then from Pitocin, or breaking your water, often the contractions can get to be more intense, and then because of Pitocin, you have to be monitored. We have to monitor the baby’s heart rate, and if the hospital doesn’t have wireless monitoring, if you’re just connected to the machine, then that can restrict your mobility. The contractions can potentially be more intense and then it becomes potentially more difficult to manage the contractions. Then you get an epidural, so you can see I’m adding things, adding things, adding things. 

And then the epidural can sometimes cause changes in the baby’s heart rate or add that with Pitocin, and then you worry that it can potentially increase your risk for a cesarean birth.  

Lozada: So, yeah, there’s a lot that you just listed there, because it is, it’s like a snowballing effect, right? One thing, and then possibly the other, and the other. So, let’s go through some of those interventions, cascade of interventions that you mentioned, and kind of break it down a little bit more of what to consider and what they’re all about. You talked about the breaking of the waters. Tell me more. 

Rankins: Yeah, so the water is eventually going to break at some point whether it’s… It can be all the way up until birth, but at some point the water will break, and typically breaking the water artificially, which is called amniotomy, where we use a hook, and I had a picture of the… I was doing some things on my computer and my daughter is like, “Is that a crochet hook?” So, people say it looks like a crochet hook. 

Lozada: A really big one. Yeah. But it’s plastic. It does look like a big crochet hook. Yeah. 

Rankins: Yes, yes. And we nick a hole in the bag of water and that causes the water to break, so the risk of that are that it will… It removes the bag of water, which acts as a protective barrier around the baby. We all have bacteria in our vaginas and that bacteria can get to the baby potentially, and the water is what protects babies from that. So, it will increase the risk of infection after about 24 hours or so. The risk of infection starts to go up. So, that’s one thing. 

Number two, it acts as a cushion, so it doesn’t… The cord doesn’t get compressed and things like that during the course of the labor. When the cord gets compressed, sometimes the heart rate will drop. Babies typically in my experience, I feel like they sense that, “Hey, something’s going on and I’ve cut off my blood supply,” so they roll off their cord or they move around, and things get better. But it will potentially cause changes in the baby’s heart rate because the water isn’t there to act as a cushion. 

And then the other issue is that if the water is broken and the baby is too high in the pelvis, if the umbilical cord falls in front of the head, that’s a true, true obstetric emergency where you have to run back for a cesarean birth, because the cord will get compressed very quickly and then that’s emergency C-section. So, those are the risks. 

The benefits are that breaking the water is something that will happen at some point anyway, so it’s not as though you’re doing something that isn’t a part of what’s going to happen with labor, and it typically will speed up labor or help the contractions be more intense. But you can’t have any… You don’t have any control over the effect, so you can break water and then it won’t start contractions for two hours, or three hours, or however many hours. There’s no way to predict that. So, it’s unpredictable in terms of the effect that it will have.

Lozada: And that it has those potential risks of that the baby might not be too happy about it, or it can make contractions more intense. 

Rankins: Yes. It can make contractions more intense. Yes. That’s the other thing. So, we don’t break the water unless we’re confident that the head is nice and well applied to the cervix and the risk of that umbilical cord prolapse is low, because it really is truly like a run to the back C-section. 

Lozada: So then, another really commonly known first intervention is the induction. Can you tell me more about that one? 

Rankins: Sure. So, induction is when we try to get the body to go into labor before labor starts on its own, quite simply. And there are very methods of induction. Things like Pitocin, prostaglandins, which are another class of medication, Cytotec, Cervidil, Prepidil, a gel, and then what’s called mechanical dilators, like a balloon catheter to help open up the cervix, which may be considered less invasive. They’re not as medication oriented, but induction is going to be things to help bring labor on its own, and then there’s a spectrum of how… of what we do and how it works in order to bring about labor in terms of side effects, and risks, and benefits of each. That’s like a whole nother conversation. 

Lozada: And we’ll link in the show notes. I have podcast episodes that talk about the whole induction process, so yeah, we’re not gonna get into that here today. 

Rankins: Yes. I will say that induction is… With the ARRIVE trial, it has… We’ve swung too far on the pendulum of like recommending almost that everyone gets induced at 39 weeks, and that the data from that trial just isn’t really there to support that in my opinion. It can be offered but doesn’t need to be recommended. 

Lozada: And I feel it’s really important that you say that because I have also seen sort of a more cavalier attitude towards inductions. No big deal. When that means gets you into the hospital, and gets you monitored, and gets you people looking at you, and trying to make sure that things get moving, and something happens way earlier than you would otherwise. 

Rankins: So, on balance, when you’re in the hospital we tend to do things, or offer things, so you’re more likely to have things happen when you’re in the hospital. Now, a lot of that depends on the hospital and the culture of the hospital. I happen to work at a hospital that’s very comfortable with low intervention, but in general, like stay home as long as you can, because once you get to the hospital there’s gonna be more temptation for interventions. 

Lozada: So then, okay, say you are having an induction, or for some reason your labor would slow down, and there’s a need to bring in some Pitocin to augment things. What are some of the risk benefits of Pitocin? 

Rankins: Sure. So, Pitocin is the synthetic version of the naturally-occurring hormone, Oxytocin, that brings on contractions. It does other things, but it does contractions. And the benefits are that it will help bring on your labor, so it makes you have contractions, contractions are what causes your cervix to open and dilate, so that’s the benefit. The risk and particularly where we get into the risks are doing too much Pitocin, so the risks are that it can affect the baby’s heart rate and cause changes in the heart rate if there are too many contractions back to back to back. If you’re on Pitocin for a really long period of time, sometimes it can increase the risk of postpartum hemorrhage, and when you talk to folks, birthing people that have had birth with and without Pitocin, they almost universally say that Pitocin contractions are stronger. 

So, they will typically be more intense, and I think the way we get into trouble with Pitocin in terms of causing or precipitating the cascade of interventions again is giving too much, and not realizing that Pitocin… It doesn’t have to stay on. You can use the Pitocin until labor starts and then you can turn it back. You can turn it off once the birthing person’s own natural labor kicks in, for sure. It doesn’t work more effectively the more that you give it. You just need to get it to the level that it’s working and then either leave it there or turn it back or turn it off. 

Lozada: And then just bringing it back a little gives that person that space they need to get back on top of it and then realize, hey, your body’s taking over, and then as you say, yeah, the permission to turn it off. 

Rankins: Exactly. Yes. Yes. Yes. For sure. Yep. 

Lozada: And so, that would be one way to, by being vigilant with what’s happening with your body and if your process is taking over, that’s one way of eliminating or lessening the chances of going down the cascade of interventions. Nicole, let’s talk about continuous monitoring. 

Rankins: Yes. 

Lozada: Because truthfully, continuous monitoring is not evidence based for low-risk people. 

Rankins: No. In low-risk women, and ACOG says this, this isn’t like a secret, and ACOG is the American College of Obstetricians and Gynecologists. It sets standards for maternity care for obstetricians, particularly in the U.S. In low-risk women, has not been shown to have a lot of benefits. In fact, some harm, some would say. The only thing it reduces is neonatal seizures by a tiny amount. Otherwise, it increases the risk for cesarean birth, increases the risk for assisted vaginal delivery with vacuum or forceps, so it has not been shown to be beneficial. And you’d think it would, right? Because you would think that you’re monitoring the baby all the time, so you’re gonna catch anything before it happens. But what happens is that we get concerned about the heart rate and then that triggers interventions or cesarean birth. 

Lozada: So, we talked about the induction, and if you’re having an induction, then most likely you’re having continuous monitoring too, so those two go hand in hand. So, then things get more intense, and then you’re more likely of wanting some pain relief medicine or an epidural. What are the risks and benefits of it? 

Rankins: I mean, the biggest benefit is that it’s extremely effective at reducing pain, so it works. It’s the most effective pain relief. I mean, when it works. 

Lozada: It is. Yep. 

Rankins: Yeah. When it works, it works, and it reduces the sensation below a certain level, like it reduces all sensation. The best epidurals, you can’t feel the contractions, or you feel them, and you know that they’re there, but they’re not terrible, and you still have some movement, so you still have some motion in your legs so you can still feel some sensation, so you know where to push, so that’s the ideal sweet spot for an epidural. 

So, some of the risks are that the medication can decrease your blood pressure, which will in turn decrease your baby’s heart rate potentially. Now, the fix for that is to get your blood pressure back up and that’ll fix the baby’s heart rate, but sometimes some obstetricians either don’t wait long enough, or get concerned and not really addressing the blood pressure, they see the heart rate and run back for a cesarean. That tends to happen within the first half an hour or so after getting an epidural. 

Lozada: Oh, and is also why they give you a couple of bags of fluids before getting the epidural to sort of shore up the blood pressure. 

Rankins: Yep. Exactly. 

Lozada: So that your blood pressure doesn’t tank. 

Rankins: Exactly. Yeah. Yeah, so that… So, there’s that risk. Epidurals can cause you to have a fever sometimes. We don’t always know why that’s the case, but it can cause you to have a fever. I think the biggest, and I don’t know if this is a risk, but the fact that if you are really, really numb, you have a hard time focusing when to push, and it can make pushing longer. It also takes away your ability to move, so you have to have a nurse who is proactive about moving you in different positions. Those tiny little millimeters of space will make a difference for a baby coming down in the pelvis the right way. 

When you don’t have an epidural, you’re gonna naturally move, and change, and you lean, you squat, all of those lunges, all of those things that help move baby down into the right position. You don’t have that with an epidural, so you have to move, you have to do things like the peanut ball to open your pelvis, make space, get those millimeters. So, you don’t want to be like just laying in the bed all the time, because that doesn’t help facilitate the best position for birth. 

Lozada: Yeah, and then I find that usually then you get situations where baby’s heartbeat is showing some decels, because they’re compressing the cord from being too long on one side, or they’re not moving around as much wiggling down the pelvis, because you’re kind of lying there, and then it starts getting very stressful, and there’s a lot of anxiety that comes into the room, and a lot more interventions. Can we talk about those? 

Rankins: Sure. So, some things that may happen in order to help fix the baby’s heart rate are like after the water is broken, whether it’s either naturally or artificially, we try to put fluid back, so that’s something called an amnioinfusion, where we put fluid back into the uterus to help provide a cushion, and that requires something called an intrauterine pressure catheter, where you have to put the fluid through, so you have to put that in. Also, other interventions, and this is called intrauterine resuscitation, so intra, inside, uterine, while baby’s still inside the uterus, and then to give the baby some help. 

Position changes, the amnioinfusion, also a bolus of IV fluids, sometimes oxygen, those are the things that we do to try to help improve the baby’s heart rate. 

Lozada: Yeah, and I find that all that also comes along with what I see happen first before all that is an internal fetal monitor, just to get a better handle on baby’s heartbeat. 

Rankins: Their heart rate. Yeah, and that is… So, yes, that is… I’m glad you said that, so that is something that commonly happens, but it doesn’t have to. If you can trace the monitor on the outside effectively using the external monitor, adding an internal monitor on the baby’s scalp doesn’t give you any additional information. So, it’s not necessary unless for some reason you can’t use the one on the outside. It’s an outdated thinking that the internal monitor gives you better information. It doesn’t. 

On the flip side, some people like the internal because it takes away the belts on the outside, which can be uncomfortable, so there are risks and benefits, but it’s not strictly necessary or doesn’t provide any better information. 

Lozada: And since we’re talking about this, let’s describe how it’s done and what it’s about, because I don’t think people quite understand that, either. 

Rankins: Yeah, so the internal fetal heart rate monitor, it’s a little electrode that’s actually twisted into the baby’s scalp. I know that sounds terrible, but it’s a little tiny wire that gets just put into the baby’s scalp and it picks up the baby’s heart rate. It’s like a little coil. 

Lozada: And so, if your water hasn’t broken at that point, then your water needs to be broken first to be able to-

Rankins: Correct. 

Lozada: … attach this to the baby’s scalp. In your experience, how often, when you’ve gotten that far along, of having an intrauterine pressure catheter, and having internal monitoring, and having done the amnioinfusion, all these things, oxygen, in your experience, once you get to that point, how likely is it that a vaginal birth will be possible? 

Rankins: Yeah. I think it’s actually still pretty likely. It really depends… I mean, a lot of that depends on the provider, and I will also say that most people that get an epidural or even Pitocin don’t end up with a cesarean and don’t necessarily end up having all of these issues. It does increase the chances, but it’s not like a guaranteed, slam dunk that if you start Pitocin or that if your water gets broken, or that if you get an epidural, that all of a sudden it’s gonna end in cesarean, because actually it’s not… A lot of that is again dependent on the provider and the hospital and the culture, but I would still confidently say that most of the time it doesn’t necessarily end in cesarean. 

Now, this is a little bit tricky for me, because I’m speaking from my experience in the hospitals and places where I’ve worked, which have fortunately been places that give labor a lot of time, but not all places and providers are like that, so it can really vary a lot. So, you just have to have a sense and a feel for… I say this constantly, how the approach of birth, the way the hospital, the way your doctor approaches birth is gonna be hugely influential. 

Lozada: Well, which ties beautifully with my last question, which was gonna be are there ways to minimize interventions? And so, you and I both agree that who you enlist as your care provider and who is in your birth team, that’s a huge, important decision that really is gonna determine, and guide, and affect how your labor and birth experience progresses. 

Rankins: Correct. 100%. And the time is not when you get to the hospital to find that information out. You must ask those questions during prenatal care. So, if you’re interested in a low intervention birth, so asking like what is your experience, what is the hospital’s experience, how do you feel about doulas, doulas are great in that regard. And so, asking those questions ahead of time, so you go into knowing what you’re working with, so to speak. 

Lozada: Definitely. 

Rankins: And then going along with that is good childbirth education, like wherever… There are lots of options out there. You have to find what works best for you. But please do childbirth education, because it will help you understand the process of labor, and the interventions, and the things to look for, and questions to ask, so childbirth education is really important. 

Lozada: And I love that you said look into doulas, because I’ve got stats for that. So, in terms of continuous support, from the website, Birth by the Numbers, which is a fantastic website headed by Dr. Gene Declercq, the latest stats that I have on doulas and how having doula support can lessen the chances of having a cesarean, people that didn’t have a doula had 34% chances of having a cesarean, whereas people who did have a doula, that percentage dropped to 9%. Now, the sample was small, but still, right? 

Rankins: Yeah. So, I mean I have a background in research, and I don’t… The things that I say, I always try to look for data. It is slam dunk, research proven, that continuous support from someone like a doula, other than your labor nurse, will improve your outcomes in a multitude of ways. Reduce the cesarean rate. You’re better able to tolerate the discomfort of labor, pain of labor. You’ll feel better about your experience. So, tons of evidence to support that, and I know sometimes it can be a cost barrier, or difficult. I always say this is a great thing to put on your baby registry if you can, or ask people to help support you with, because it’s like the benefits and the return on investment is a lot. 

Lozada: Nicole, is there anything else that we need to talk about relating to the cascade of interventions?

Rankins: Yeah. I just think in general, we all know that birth is an unpredictable process, and none of us can predict how it’s gonna go. The baby runs the show, and they don’t tell us what they’re gonna do. So, the more that you are prepared and empower yourself with information, and have that before you go into your birth, the better able you’ll be to manage those curves if they come. And they may not come, you know? I’m not saying it’s gonna be that way, but you’ll be able to handle the things that will come your way, and you will feel more peaceful afterwards if things don’t. Even if they don’t go exactly as you planned, because you’ve done everything that you can do within your power, and you know what to expect, and you have some ideas, because ultimately I see that it is not at the end that people feel that they’re happy about their birth because they did it without medication, or they… It’s not the pain relief or anything. It’s that they felt good, they felt respected, they felt empowered going into that experience, and that’s how you’ll feel good on the other side. 

Lozada: And to feel that birth happened, and you were an active participant, and you were involved in shared decision making.

Rankins: Yes. Exactly. 

Lozada: And not that things were done to you, because that’s where trauma sets in. Thank you so much for being here today. I really appreciate talking. It’s so much fun. 

Rankins: Oh, thank you for having me. 

Lozada: That was board certified OB/GYN and hospitalist, Dr. Nicole Calloway Rankins, who is also the host of the podcast All About Pregnancy and Birth. You can find her on Instagram @DrNicoleRankins. 

I hope that your main takeaway from our conversation is that although some interventions can be beneficial, you need to understand the risk of any and all interventions and how they may lead to more interventions so you can be informed, prepared, and able to decide whether they make sense for you, your labor, and your baby. 

One thing you can do for you is to proactively set in place positive interventions during birth and immediate postpartum, such as hiring a doula or including doula services in your baby registry and advocating for as much immediate and abundant skin-to-skin time with your newborn following their birth. The one thing you can do for the rest of us is to follow and support the White Ribbon Alliance. Their global work advances evidence-based perinatal care in alignment with the more conservative guidelines for labor augmentation and induction set down by the World Health Organization. Learn more at WhiteRibbonAlliance.org. 

You can connect with Birthful on Instagram, @BirthfulPodcast, and to learn about Birthful and my birth and postpartum preparation classes, go to Birthful.com. 

Lozada: Birthful was created by me, Adriana Lozada, and is a production of Lantigua Williams & Co. The show’s senior producer is Paulina Velasco. Jen Chien is our executive editor. Cedric Wilson is our lead producer and Kojin Tashiro mixed this episode. Thank you for listening to and sharing Birthful. Be sure to subscribe on Apple Podcasts, Amazon Music, Spotify, and everywhere you listen, and come back next week for more ways to inform your intuition. 

CITATION: 

Lozada, Adriana, host. “How to Avoid a ‘Cascade of Interventions’.” Birthful, Lantigua Williams & Co., March 3, 2021. Birthful.com.