The Cascade of Intervention

Many things in life have unintended consequences: they may or may not have the effect that we want, and sometimes they have 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 idea that using one intervention can lead to the need for more interventions is called a "cascade of intervention."

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 medicine (“Pitocin”) to make labor move faster.
  • Giving medications for pain relief.
  • Laboring in bed versus being upright and moving about.

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

  • Interfering with hormones that move labor and birth along.
  • Creating opportunities for infection.
  • Having undesirable effects on your baby.
  • Making it harder for you to push your baby out.

When these effects happen, women may feel that their bodies have failed them, not realizing that the things that went wrong could have actually been triggered by maternity practices themselves.

Limiting the Cascade of Intervention

Almost every intervention has some potential to cause harm. You should use care in deciding whether to have an intervention. 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. You will find a lot of this information in the Giving Birth section of this website.

Unfortunately, it is impossible to predict in advance exactly what may happen during your labor and delivery, or how a given intervention may affect you or your baby. The best way to limit a cascade of intervention is to become informed, get all of your questions answered, and put plans in place in advance that will help avoid potentially harmful interventions.

Here are some tips for avoiding unnecessary interventions:

  • Choose a care provider and a birth setting that have low rates of using common interventions.
  • Become familiar with the best available research about interventions that are most likely to trigger a cascade of intervention, including induction of labor, epidural analgesia and other pain medications and cesarean section.
  • Have an open and respectful conversation with your care provider about why you need any recommended interventions. It’s ideal to have this conversation well before you may need the intervention so you can express your wishes and discuss plans.
  • Talk to your care provider about options like “watchful waiting” (doing nothing and waiting for labor to move along or for issues to resolve on their own) or using simpler, less invasive alternatives.
  • Learn about the benefits of continuous labor support and consider engaging a doula to help you achieve your objectives.
  • Clearly communicate your wishes to your care providers, and get the support of your spouse, partner, doula or other companions to reinforce your wishes throughout labor and delivery.
  • Know that you have the right to accept or refuse procedures, drugs, tests and treatments, and to have your choices honored.

The Cascade of Intervention in Action

Epidural analgesia is a good example of the cascade of intervention. It can provide very effective pain relief during labor, but 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 negative effects.

Interventions like electronic fetal monitoring and intravenous fluids are often used with epidurals to monitor, prevent or treat these effects. And others become more likely (synthetic oxytocin to strengthen contractions, catheter to empty the bladder, vacuum extractor or forceps to help move the baby out). These in turn may have side effects that lead to the use of yet more interventions.

Babies can also be affected. For example, epidurals increase a woman’s likelihood of developing a fever, which can make doctors worry that the baby has a fever. This leads to blood tests and antibiotics for the baby after birth. They may also be observed in a special nursery, which can interfere with mother-baby bonding and breastfeeding.