219. "The Cascade of Interventions": Quick Kick

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0:43 Welcome back to the show. I'm Bridget Maloney, and today is a quick kick for anyone who has heard of or is concerned about the term cascade of interventions. Now, if you spend any time on Instagram reading birth forums or listening to natural birth advocates, you've most likely heard this term. Simply, it's that you agree to one seemingly minor medical procedure, and like a row of falling dominoes, it triggers a chain reaction of further interventions, eventually leading you down a path to an assisted birth or an emergency C-section.

1:14 But what does the actual scientific data say? Is the cascade a proven medical risk or is it a clinical myth? Let's take a snippet of both sides of the research. On one side, there is data showing that the cascade is a real phenomenon for low-risk women. For instance, a major population study out of New South Wales looked at over 343,000 births, and they found that over 25% of low-risk first-time mothers experienced a direct sequential cascade, starting with an induction or augmentation, moving to an epidural, and ending in an instrumental delivery or an unscheduled C-section.

1:50 There is strength to this research paper due to the massive sample size, but critics also talk about the method where variables were hidden. And we'll talk about that in a minute. Another large systematic review published in the journal Birth showed that routine interventions like continuous electronic fetal monitoring at admission were directly linked to a higher likelihood of getting an epidural.

2:13 That epidural was then structurally linked to an increased use of syntocinin or synthetic oxytocin and a higher rate of instrumental delivery. Advocates of this research argue that routine interventions disrupt our natural birth physiology, confining you to have your labor in bed and turning to medical interventions that turns into a self-fulfilling prophecy.

2:39 But on the kick, longtime listeners will know that we talk a lot about medical nuance that decisions are made. So, yeah, let's talk about that. Because there is another massive body of modern research that heavily counters this argument. Firstly, there is the landmark randomized controlled trial. So that's the best form of research called the Arrived trial.

3:03 And then a subsequent meta-analysis of more than 150 randomized controlled trials published in the Canadian Medical Association Journal. These studies turned the traditional, you know, induction cascade, cascade of interventions theory on its head. They found that healthy, low-risk women who were electively induced at 39 weeks actually had a lower risk of needing a cesarean section compared to those who waited for spontaneous labor.

3:31 Researchers in these papers also point out that another major flaw is the anti-intervention argument called confounding by indication. So we have touched on this before throughout all our podcasts, but I'll give you an example to help in the understanding. So confounding by indication is if a person is induced because there's, say, blood pressure is dangerously high, or maybe because the placenta is failing, and ultimately their labor ends up with a C-section.

4:01 It wasn't the induction necessarily that caused the C-section. It was the underlying medical condition. The sequential interventions are there to manage a developing problem, not to maliciously create one. Now, the arrive trial also has its critics. Researchers have said that because doctors in the trial knew that they were in the trial and being watched, and this is actually called the Hawthorne effect, that they modified their behavior to perform better.

4:27 And in understaffed public hospitals, these results just can't be replicated. So, where do we go to from here? We know that this is a phrase that you might have in your mind when you're thinking about labor and birth. And we have had a great question on our speak pipe that we've covered previously in a QA.

5:16 Let's just take a listen to that.

5:19 Hi there. My name is Claire, and I'm currently 14 weeks pregnant. Thank you for the opportunity to ask questions. I really enjoy the podcast. So I've seen a lot of discussion, especially on Instagram, about the cascade of interventions. The messaging I found around this is often quite careful. It talks about basically once you open the gate, then everything just rushes in.

5:45 I wanted to get your thoughts. Well, first of all, what is the cascade of interventions and your thoughts on whether this is a risk that we should be worried about when giving birth? Further to this, I've also seen claims that an induction will significantly increase your chances of having a C-section.

6:03 Also interested in hearing your thoughts on this and whether it's true. Thank you.

6:08 Now, the reason this is a big topic, and I think actually we should do a whole podcast on the cascade of intervention. But I just I thought maybe we could do like just a five-minute snapshot of your thoughts on cascade of intervention.

6:21 Alright, here we go. I think that the term cascade of intervention, what we're talking about is this idea that um if we interfere in a labour that we may create a problem that needs further interference in the labour, and then by doing that further one, we create a problem that needs another one. And there's a there's an idea which I think is perhaps a little overly simplistic, that if we just don't interfere in the first place, we won't cause all the other all the other interferences that might flow from it.

6:56 Okay. So I think a really good way of illustrating the complexity of the discussion is if we talk about epidurals. It's commonly believed that if you have an epidural in labor that your labor would probably slow down, therefore you might need more cintocinone. And then if you have a whole lot of cintocinone, we might force the baby into an abnormal fetal heart rate that we then freak out about and do a cesarean section.

7:22 Okay. Now in my view, that is something that certainly happens and it's something that we certainly should be cautious and trying that that we to stop it happening. What we d don't it doesn't necessarily follow, however, that if the first intervention is something that's a very, very good idea that negative consequences need to follow from that.

7:49 So for example, if someone says to me I um I don't want an epidural because I'm uh afraid of the consequences that might come from that, then sometimes I'll say to that person, Well, let me give you another scenario. Let me give you a scenario where you're in labor and it's taking an awfully long time and you're um in pain and distressed.

8:11 And what we really want to do is use a cintocinon infusion to make your labor go a bit faster. And in order to to do that, given that you're already in a lot of pain, why don't we put in an epidural? Take the pain away, put the cintocin up and push you on. Now what we're trying to d achieve by doing that is getting that woman too fully dilated so that a normal birth, a vaginal birth is on the table.

8:39 If we didn't push the labor along and the labor was taking way too long, that can correlate with poor outcomes and it can correlate with high cesarean section rates if the labor is way too slow. So in fact, we've used an epidural to increase the chances of that woman having a vaginal birth not decreasing.

9:01 So in that scenario, that's seen as a terrific idea and a genius move and not a cascade of intervention. So my I know you said five minutes, but there's a complicated one. My view on this is that is that I don't know that it's terribly helpful to talk about cascades of intervention because the implication is that any intervention is bad.

9:24 I think what we should really be doing is saying every intervention has a potential benefit and some potential downsides. And we should be very careful about using intervention. And every time we go to use intervention, we should be using all of our knowledge, all of our learnings, all of our experience, all of our dedication to women's well-being to say absolutely am I doing this for the right reasons?

9:53 Um is this going to help? And and are the known downsides to this intervention worth it for the benefit that I'm trying to bring about?

10:05 I'm gonna put a little plug-in for our program, the Grow My Baby program, because the birth module alone is like 15 pieces of information. Yeah. And you might, as the person having the baby, you might be the person that has to assess these interventions that are suggested. Yeah, you know, with your partner.

10:28 Yeah. And that's why we made it, isn't it?

10:29 Because you've got to learn about it.

10:31 You've got to learn you've got to know more, not less. Yeah. Yeah. Yeah. Because ultimately it may come down to you to decide on on on the advice of your team.

10:41 Yeah.

10:41 But ultimately you may need to decide what are the what are the risks in going more than 41 weeks.

10:48 Yep.

10:49 Do I like those risks or not?

10:50 Yep. And especially if you're in a busy public, obstetric hospital where you don't have a primary kind of caregiver, you have a team. Um, and people aren't sort of following your pregnancy along, um, and then you're in a space where you don't really know anyone um having a baby. So yeah, yeah, you've got to be the one that knows the risks, the benefits, can make those decisions.

11:13 And um, yes, we we definitely do cover that in in in good detail, where you can feel um like you've got the knowledge to then say, yes, no, what happens if I do that, what happens if I do nothing?

11:27 Yeah, or at least to feel part of the discussion.

11:29 Yeah. Can I put my own little plug-in for the cascade of intervention? So for those that are new to us, I had my first two babies before I met Pat. Um, and in my first pregnancy, I just was hell-bent on not having any intervention because of this very term cascade of interventions. It was really drilled into me.

11:48 Don't let them near you because then you'll have this cascade of intervention. I could have had one major intervention that would have changed my first birth dramatically, and that is I could have said yes to an induction. So I went to 42 weeks. By then my babies were massive, big, massive heads. Um, and if I perhaps had have not been so stubborn and not been so anti-intervention or putting it lumping all the intervention into one big pool and saying all intervention is bad, I think that perhaps I would have had a different outcome.

12:21 Yeah, you might I guess maybe. You might have been able to divide the concept of uh of intervention into one list of interventions that that would be uh deal breakers for you. Or and another list of yeah, they're things I'll consider if you can convince me that the benefit is more worse than the risk.

12:38 Yeah, I think I should have said that to all interventions, to be honest. You know, they in my in my now that I know so much more about birth um my thinking has changed so dramatically to me thinking that every intervention should be assessed on its merit, and I wouldn't put any intervention into a deal breaker.

13:00 Yeah. Yeah.

13:01 That's where I've got to. Da-da.

13:04 Well well done. My work here is done for Debian.

13:09 I love how Dr. Pat explained his view on the cascade of intervention. You know, birth for so many of us can represent a loss of control. And I think the term cascade of intervention even sounds like we're freefalling. And that perception of loss and control is truly frightening. So, how do we respond to when an intervention is suggested?

13:29 This can be within our control, but not through absolute thinking, like using terms like under no circumstances. Or I've got another example for you. One of our doctors who also works in a busy public hospital recently told me that a patient had put on the door of the birthing suite she was in that said, no doctor under any circumstances is to enter the room.

13:51 So I appreciate that this is done because of a fear of the cascade of intervention and the thought that every intervention is bad. So let's talk about what is within our control. This is knowing the pros and cons of the different interventions, seeing our midwives and doctors as part of our birthing team, having the knowledge to ask what are the risks and benefits.

14:16 What if I do nothing? Asking, what if we just wait? Or can I have more time? Now, the next crucial step is to have a good enough knowledge bank about interventions before the day of the birth. And please don't forget your birth partners, they need to be up to speed too, so they can help you on the day to make decisions that are based in your knowledge bank.

14:41 So if you're thinking, oh my gosh, there's so much for me to know, it's okay, we've got you. If you go back through our episodes, we've covered so many of the interventions, and this is all free for you to listen to. Um, in the QA, we talked about our Grow My Baby program, and this is available to everybody wherever you are in the world.

14:59 Uh, it's a self-paced program where you can just touch base with the information that you need at the time that you need it. Now, we all consume media that is written with a hook based in fear, because in marketing that works. The antidote to that is knowledge. So, congratulations to you for taking the time today to increase your knowledge bank.

15:23 And if you want to help others increase their knowledge bank, there are two ways you can help them. The first is to hit the subscribe button to wherever you are listening to this episode so it gets pushed through the algorithm to others just like you. And the second is to simply share it with a friend.

15:38 So that's it for now. Please, everyone, keep well, keep growing those babies, and we'll be in your ears next week. Bye for now. Hey, even though Dr. Pat is, well, a doctor, and we get lots of other doctors and other experts on our podcast, I just need to remind you that this podcast is for informational purposes only.

16:02 We share lots of medical insights and experience, but everything we talk about is general in nature and may not apply to your specific situation. Please always consult with your own healthcare provider for your individual medical advice when you grow your baby.