Interventions in Pregnancy and Labour
There is a discrepancy in the UK (and some other countries like America) in the number of births which have medical intervention, compared to how many it would be expected should need it. WHO (World Health Organization) and our own Royal college of Gynaecologists and Obstetricians estimate that only 10% of births should require intervention.
However, in the UK, NHS Maternity Statistics show that the combined caesarean and assisted birth rate is at around 48% and around 32% of labours are now induced. Obviously, this is much higher than the 10% which is estimated to actually require this kind of assistance.
The reasons why this may be so much higher than it should be are complex, and are in part related to the cascade effect which can come from even what appears to be the smallest intervention. This is why being informed about your choices and preferences is so important, and why writing a birth plan can help you to research this.
What counts as an intervention?
Basically, anything outside of what a woman will naturally do if left undisturbed to birth her baby, is an intervention. So this includes:
- Induction or augmentation of labour
- Use of pain relief
- Directed second stage pushing
- Vaginal examinations
- Being directed to lay immobilised or on her back in labour
- Monitoring of baby
- Assisted birth (ventouse or forceps)
- Caesarean Section
What is the cascade of intervention?
While we are fortunate to have access to the choice of medical intervention if we want or need it, they do come with an important downside to also be aware of. It is common for interventions to have a snowball effect – and this is called the ‘cascade of intervention’.
Simply put, all interventions have consequences. There will be the hoped for consequences of having the intervention, but there may also be unintended consequences, which require another intervention to manage. The second intervention may deal with the unintended consequences of the first intervention, but may also have its own set of unintended consequences which lead to yet another intervention (and so on). Hence, the snowball, or cascade, effect.
Here is an example of a possible cascade of intervention:
Mum is in labour – both she and baby are fine
Labour is not progressing as quickly as medical professionals would like.
Labour is augmented to try and make it progress more quickly
(waters are broken and syntoncin drip is administered)
The artificially stimulated contractions are much harder to manage and so mum has an epidural
Epidural means Mum is immobile and loses sensation.
Mum finds it difficult to birth Baby naturally due to lack of sensation and being immobile
Mum required an episiotomy and a forceps delivery.
Mum required postnatal stitching.
Mum finds it difficult to establish breastfeeding
This is just one example of a possible cascade. In this example, it also feasible that there would not be any undesired side-effects, but it is also possible that the side effects could have been even more severe, with foetal distress and an emergency caesarean becoming necessary.
So are interventions bad?
No! It is not that simple. Interventions absolutely have their place. For the births which do need some assistance, then obviously our access to medical support leads to lives being saved.
However, interventions are used and offered in non-emergencies too, and the smallest intervention can lead to a much bigger one. So it is important to think through some of the interventions you both might be offered or wish to use in a straightforward birth, so that you understand the potential risks which also exist, and can make an informed choice.
When it comes to interventions, you always have a choice. Sometimes it will be an obvious choice – if your baby or partner are in distress and need assistance, it is a no-brainer. But where ‘smaller’ interventions are used/offered as routine, that really comes down to your preference.
Interventions – A Closer Look
Closer look 1: Induction and Augmentation of Labour
Induction of labour basically means kick-starting labour rather than letting it start of its own accord. Augmentation of labour means trying to make labour progress more quickly.
These interventions can be suggested for several reasons, induction and augmentation will be offered when medical professionals believe it is safer for mum and baby to birth earlier. However, induction can also be often offered when labour has not started by itself by, or soon after, the due date.
Induction is a common intervention, and because it happens before labour begins, sometimes parents miss it off their birth plan. Statistics show that 25% of labours are induced in the UK, at some hospitals, it can be as many as 32%. However, as induction will usually massively impact on how the birth unfolds and some of the choices available to you both, it is important to see it as part of your birth choices and to think in advance about how you feel about it.
NICE Guidance acknowledges that there is an increased likelihood of requiring pain relief and an assisted delivery with induction. In first time parents, there is also evidence which suggest that there is a correlation between induction and caesarean section. Induction therefore, can have an impact not only on your birth this time, but also subsequent births, as women who have a caesarean with their first baby, are more likely to have them with subsequent pregnancies.
Choosing whether or not to be induced is often not an easy decision because there will be risks to consider on both sides. It becomes about working out what risks you are both prepared to take, understanding the measures you can use to minimise those risks and doing what you feel is right in YOUR circumstances. There simply isn’t a risk free option, there is always a risk with every decision.
What are the options if we are offered induction?
Option 1 – To say no.
You can always say no. Induction is your choice. NICE guidelines state ‘If a woman chooses not to have induction of labour, her decision should be respected. Healthcare professionals should discuss the woman’s care with her from then on.’
If you do decline the induction of labour, you should be offered regular monitoring to check how your baby is, and if there are any concerns at all, professionals can let you know, so you can reassess your decision to wait.
It is also helpful to think about the fact that you can say no, meaning not today. Saying no today, doesn’t mean you can’t change your mind and say yes tomorrow.
Option 2. Try natural methods of induction first.
If you want to get things moving but don’t want to use medicalised means, you could try natural methods to kick start things. Whether these are old wives tales or there is something more to them is up for debate, but it is a choice open to parents-to-be.
Some of the key ones you might want to try are:
- Sex. Not always highest on the list when your partner is heavily pregnant, as it can be tricky, but making love releases the labour hormone, Oxytocin, which is responsible for labour beginning and progressing. Birth Basics. Semen also contains prostaglandins which help soften the cervix.
- Hugs. If sex isn’t on the agenda, cuddles and hugs have a similar oxytocin boosting effect!
- Eat some spicy food. It is thought that the spices stimulate the bowel, which gets things moving… not proven as being effective, but worth a try if she likes spicy food?
- Nipple Stimulation. Again this can stimulate the hormone oxytocin.
- Walking. Harnessing gravity to encourage the baby to drop further, stimulating the release of oxytocin.
- Accupressure or acupuncture. Many testify to this getting labour going, and it is usually a nice relaxing way of achieving it too!
The main word of warning with all of these options, is that no matter how natural this all still is, it is still an attempted intervention/induction. This means that some of these methods may still have side-effects, such as an upset tummy from the spicy food, or labour coming beginning very strongly from an acupressure treatment.
Option 3. Choose medical Induction
If you choose a medical induction, there are several possible methods which can be used. This will usually be determined following monitoring and a vaginal examination to assess what is known as your partner’s ‘Bishops Score’.
No Bishops are actually involved, this is a vaginal examination to see how ‘favourable’ her cervix is – i.e. whether her body has already started making progress in terms of preparation for labour. If her cervix is deemed ‘favourable’ it means that induction is more likely to be successful. However, if the check shows the cervix is unfavourable (i.e. the body has not yet started preparing itself for labour) then induction is less likely to work – which is a pretty common sense way of looking at it!
The method of induction offered, depending on the assessment of the Bishops Score, could be:
- A Sweep: A sweep is normally carried out by a midwife. Similar to a vaginal examination, the midwife will insert her fingers into your partner’s vagina, stretching the cervix and sweeping her fingers across the membrane. Sometimes this can stimulate contractions within the next day or so, however it may not have any effect.
Risks to bear in mind include accidentally breaking the waters during the examination, and as with any vaginal examination, there is always a risk of introduction of infection.
- Pessary, Tablet or Gel: This is inserted into the vagina and contains prostaglandin which is a hormone to help soften the cervix.
Risks of this method can include uterine hyperstimulation – which means contractions last longer and come more frequently than should be safely expected. Uterine hyperstimulation can lead to uterine rupture, foetal distress and other associated complications.
- Artificial Rupture of the Membranes:This simply means artificially breaking the bag of waters around your baby. The midwife inserts an instrument into the vagina, through the cervix to rupture the waters. The aim is to remove the cushion of water between your baby and the cervix, to put more pressure on the cervix with the aim of increasing the pace of labour.
Whether the evidence supports this practice is a subject up for debate. One review of the studies reported that the evidence did not show it made the first stage of labour go any quicker, while there was a possible link to an increase in Caesarean Section.
Risks include increase in the intensity of contractions felt by Mum, foetal distress.
- Syntocinon: This is an artificial form of oxytocin, the hormone that stimulates labour. It is normally administered through an IV drip in the hand. Syntocinon brings on contractions, which can be very strong. Guidance under NICE (National Institute for Clinical Excellence) states that if you are offered Syntocinon, you should also be told that it is more likely that you will need pain relief.
Risks include uterine hyperstimulation and therefore the associated risks including uterine rupture and foetal distress, as well as possible side effects such as nausea, headaches, fall in blood pressure, heart problems, etc.
Closer look 2: Use of pain relief
Medical pain relief or very prescriptive techniques for dealing with pain are an intervention, and so it is important to look at the pros and cons of each as these can have their own cascade effect. Pain relief at the birth
This will help you to make informed choices about anything you definitely do or don’t want to use, or what you want to try first. These should all go on your birth plan so that you can communicate these wishes with your midwife.
Closer look 3: Directed second stage pushing
While you might be familiar with those scenes in the movies with people shouting at women to ‘push, push, push’ this practice has recently come under scrutiny. Directing a woman when to push and not push is an intervention – as this is contrary to a woman following the urges her body gives her at this point.
You and your partner can request for guidance on when and how to push, equally you can request for no intervention at this point and to allow your partners body to work naturally.
Closer look 4: Routine vaginal examinations
A routine vaginal examination means the checking of the cervix to determine how labour is progressing, even when everything is progressing well. Vaginal examinations are always a choice, it is not a requirement to have them done.
When deciding whether this is an intervention which you and your partner would like to use or not, it is worth considering the following:
- How it will feel or make your partner feel. How women feel about vaginal examinations varies hugely, for some they are pretty insignificant, for others they are painful or traumatic.
- There is recognised limit to the usefulness of cervical checks. They only tell the person doing the examination what the cervix is doing at that moment, not what it will be doing in five minutes or an hour. It doesn’t give an answer about how much longer there is to go.
- Assessing the cervix varies between practitioners, so it is not an exact science.
- There is the risk of accidentally breaking the amniotic sac while performing a vaginal examination. This changes the path of the birth, and increases risk for the baby.
- All vaginal examinations carry a risk of infection which is why there is a limit to how many and how frequently they will be done.
If you are happy to consent to routine vaginal examinations, you do not need to specifically mention them on your birth plan. However, if you would prefer to not have them, it is a good idea to put this on your birth plan. One may be offered routinely before someone has read your birth plan, so if the preferences is not to have them, you may need to be prepared to support your partner to say no thank you. There is a myth that because you should be in established labour before being admitted into hospital, that a vaginal examination is required to check if you are indeed in established labour or not. This is not the case (you cannot be denied access to care for declining an examination) and there are lots of other ways that labour progressed can be assessed.
Closer look 5: Immobilisation and laying supine
100 years ago, birth moved from home to hospital and with it came the practice of directing women to lay on their backs in hospital beds for labour and birth. However, in the thousands of years before this, and today in countries where women don’t routinely give birth in hospitals, this is not the position used. Quite simply it doesn’t aid birth progress: instinctively mammals stay upright, they move around, they retreat to private familiar places.
Being directed to be immobilised or lay on her back (if that isn’t the instinctive position she has chosen) is an intervention. If your partner is asked to do so, so that she can have another invention, then it is worth considering that you are getting two interventions for the price of one!
If your partner has monitoring, a drip or a vaginal examination in labour, it is your choice to ask for these things to be done in a way which avoids laying on a hospital bed. Sitting on a birth ball works just as well for drips and monitors, as does standing or kneeling. You can ask for a vaginal exam to be done in a kneeling or hands and knees position. These are not always as easy for the health practitioner to carry out as having a woman laying on her back, but it is possible.
Closer look 6: Monitoring of baby
You will be able to have your baby’s heart rate monitored throughout labour, although as with all interventions, this is also a choice and you can decline monitoring, or ask for an alternative form of monitoring, if you prefer.
Monitoring is used to listen to your baby’s heart rate, as a notable change in the rate can be a sign that baby is in distress and needs some help.
There are different ways of monitoring your baby’s heartbeat:
Intermittent auscultation. This means listening to your baby’s heart intermittently, usually every 15 minutes when your partner is in established labour. This will usually be done using a handheld doppler monitor, the same as those often used at antenatal appointments. These monitors are also usually waterproof so can also be used if your partner is labouring in water without her having to get out. This method means she remains free to move around.
Continuous fetal monitoring . Your baby’s heartbeat and your partner’s contractions may also be monitored electronically, allowing for continuous monitoring. This means being attached to a monitor the whole time, via a belt around your partner’s abdomen. Studies suggest that continuous monitoring does not make a difference to outcomes however it does come with additional risks. There is a correlation in the increased incidence of Caesarean delivery or assisted birth (forceps/vacuum), as well as the use of pain medication. This may be linked to the fact that continuous monitoring often restricts a woman’s ability to walk and change positions (as many will be encouraged into an immobilised position lying on their spine on a bed). In addition, watching the monitor can create fear, interfering with the hormone production and slowing down labour, potentially leading to other interventions. Birth Basics
Consider how you feel about monitoring and make a note on your birth plan your preference.