You have probably heard of ‘The Cascade of Intervention’. It is the idea that once an intervention occurs, the rest shall follow. This is considered a ‘Slippery Slope’. It is, however, more nuanced than a cascade and there is more than one slope. If we think of physiological birth as a flowing river, there are many possible forks. If we are unprepared (going with the flow), we are at the mercy of the strongest current, which will divert us into one of many possible forks in the river. If we are prepared (with our map), we can control which fork we will take. We can determine which will be our safest route because we understand the flows.
The Flows of Modern Birthing (above) shows the main possibilities we can prepare for. For any intervention to occur, informed consent is required. In addition to the risks and benefits, we need to know why the intervention is being offered, what other interventions will come with it and how it will change our birth journey. We also need to know our alternatives.
Let’s consider induction: Induction interventions include the ‘stretch and sweep’, hormone gel inserts, artificial rupture of membranes and synthetic oxytocin. Sometimes an induction ‘kick starts’ labour, and a woman labours and births with no further intervention. However, once a labour is induced, it will be managed. This may involve monitoring and observation, restrictions on the mother and interruptions that inhibit effective labour. The mother may now have a time frame and limit she is expected to labour to. If labour is not following this ‘schedule’, it may become augmented. This usually means synthetic oxytocin (which restricts movement and increases intensity). Often this is accompanied by an epidural, which requires a catheter, hydration drip, and monitoring. This is why it is referred to as a cascade.
An augmented labour is more likely to lead to an augmented birth. This is also called ‘assisted delivery’. This might be directed pushing, vacuum assistance, or forceps. The mother will be on her back, and may have her legs held by people or stirrups. This is also where the most significant risk of severe perineal tear occurs. (See Protecting your Perineum).
A ‘managed third stage’ is often routine, and many women do not realise they have options or even what is meant by ‘managed third stage’. Third stage refers to the time after the baby is born until the placenta is expelled. A managed third stage involves an injection of synthetic oxytocin into your thigh either as your baby is being born or immediately after. The cord is then clamped and cut within a few minutes, and controlled cord traction. Controlled cord traction involved tugging on the end of the cord attached to the placenta whilst applying pressure to your belly to extract it. This all happens very quickly, and can feel intense. There may be several attendants around you, with bright lights and lots of talking. Whilst this is happening, your baby is likely to be with other attendants in the room being assessed.
A spontaneous and unaugmented labour and birth can be interrupted by a managed third stage. This often leaves a mother feeling ‘dealt with’, rather than involved with the birth (increasing the risk of experiencing emotional trauma and/or postnatal depression). If all is well, the baby will be given to you after the placenta is out, and you can have skin to skin time as you meet your baby and settle after the birth. You will probably be moved from the delivery suite to the postnatal ward first.
By understanding how interventions are connected, we can avoid a traumatic, dramatic, stressful or crushing experience, which can result from ‘going with the flow’. Many women talk positively of their births, no matter which path they journeyed along, because they were prepared, felt respected and included, understood what was happening, and were able to make confident decisions as the birth unfolded.