Cascade of Intervention…

There is an important phenomenon all women should be aware of – the Cascade of Intervention.

This phenomenon is well recognised in the medical community and in relation to maternity services describes the idea that there can be unintended consequences to medical interventions.

Example 1:

Induction (chemical and mechanical) and the use of fetal heart monitors typically go hand in hand. Someone women do go beyond their due date and induction does become a necessary conversation. However, the use of continuous fetal heart monitoring, often paired with induction, reduces a woman’s mobility significantly, increasing dramatically the amount of time a she will spend lying on her back. This can have a notable knock on effect on her ability to labour effectively, setting off a chain of events that may result in failure to progress, ultimately increasing the likelihood of further interventions being needed.

Knowing the potential of this effect means women can investigate alternatives:

  • Continuing to do nothing (for a safe period of time), labour may still commence naturally
  • Request mobile monitoring, this is offered as a matter of course in some places, but certainly not everywhere. Being mobile reduces the impact of immobility, which in turn has the potential to interrupt a cascade of intervention

Example 2:

Some women want to use patient-controlled epidural as their form of pain management. This can work really well for some but some hospitals combine its use with the use of fetal monitoring. The potential for a cascade of intervention is therefore also present in this instance too as once again the woman can spend long periods of time immobile as the fetal monitor is used (albeit intermittently), setting off a chain of events that may result in failure to progress, ultimately increasing the likelihood of further interventions being needed.

Knowing that a diagnosis of failure to progress can, if unchallenged result in a caesarean means it is very important women understand:

  • What really constitutes a failure to progress and when intervention is truly necessary
  • The Cascade of Intervention phenomenon and which interventions can exacerbate the situation

A great source of information is the Childbirth Connection website.

“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.”

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Is there a link between depression and unplanned caesareans?

According to recent studies it seems women having an unplanned caesarean are 15% more likely to experience depression postnatally.

This probably isn’t a big surprise to some readers, but it is rather depressing.

Back in 2008, J Lally identified a woman’s expectations of her birth as highly significant. She recommended the setting and management of expectations be viewed as a key factor in helping ensure women interpret their birth positively.

Yet 11 years on, studies are still saying the same thing, but birth education has changed little. Women continue to be bombarded with strong messages about natural birth, avoiding drugs, avoiding caesareans, avoiding the difficult ‘What if…’ conversations.

For many women, the less medical intervention the better, but not only is this not the preferred route for some women, but also the likelihood of achieving a totally natural birth is actually lower than most think. Many women have no idea about rates of intervention and what the can do about them.

In the UK, some form of medical intervention – be that drugs, instruments or surgery will be involved in 50% of births (NHS Information Centre 2008) and 61% of births will involve anaesthetic (2014/15 NHS figures). And in 2017, the Birth Dignity survey in Australia revealed over a quarter of women surveyed did not achieve the birth they wanted.

It is unfortunately the case that some educators and practitioners make decisions for women about what they should and should not be told ‘in case we frighten them’. The result is that many, many women plan a particular type of birth for themselves with little, to no understanding of:

  • the likelihood of achieving it
  • alternatives to it which might become necessary
  • ideas for ways to transition between preferences as the birth progresses
  • coping techniques for interventions
  • detailed plans for caesarean delivery

Understandably, for some women then, any deviation from their birth plan can come as a tremendous shock and carries the potential for huge emotional damage. A US survey in 2011 recorded rates of PTSD in mothers of between 1.7 – 9% which can have a significant impact not only on family life and bonding with the baby but also on subsequent family planning.

Women are often just not prepared for the alternative possible outcomes of their birth plan and can struggle to manage them as a result. As an example see cascade of intervention.

This recent study, by Dr Valentina Tonei from the Department of Economics at the University of York recommends the ongoing needs of women for mental health support should be factored in to birth costs. Realising that 15% of women are likely to be depressed after their birth as a direct result of the mis-match between expectation and the experience of an unplanned caesarean (never mind other forms of intervention) suggests this has “important implications for public health policy, with new mothers who give birth this way in need of increased support…While the financial costs associated with this surgical procedure are well recognized, there has been less focus on the hidden health costs borne by mothers and their families. ” Dr Valentina Tonei

I would go a step further and say that the hidden costs of caesarean and vaginal birth are conveniently ignored in funding and planning circles:

  • An unplanned caesarean is a hidden cost of vaginal birth attempt
  • Pelvic floor surgery is a hidden cost of vaginal birth
  • Mental health support is a hidden cost of any birth that does not match a woman’s expectations

It is great that yet another study is highlighting the link between birth experience and mental health, but studies are not enough. Many women go into their birth believing they are in control of their plan, but nature is simply not that predictable even in second and third pregnancies. Women need to know that plans are great, but they are not a guarantee and alternatives need to be considered and planned for. Antenatal education must change. But so too must the funding of maternity services, which need to take account of this additional mental health cost to some women.

“Only seven percent (7%) of women suffering with mental health problems during or after pregnancy are refereed to specialist care.” RCOG Maternal Mental Health – Women’s Voices report.

So, what could this mean?

There lots of things we can do to help ourselves manage our birth experience, somethings are readily talked about:

  • Accupressure
  • Massage
  • Visualisation
  • Breathing techniques
  • Writing a birth plan

But what is unpopular, yet which really needs to be added to this list is:

  • Information about rates of intervention
  • Ideas for ways to transition between preferences as ones birth progresses
  • Coping techniques for interventions
  • Detailed plans for caesarean delivery
  • Practical coping techniques for births which have involved some form of medical intervention

Educating women about such things does not for a minute mean we should accept interventions are going to happen as a matter of course – there are definitely situations where an intervention may be suggested but is not definitely needed. The Cascade of Intervention is definitely an effect and something women need to know about.

But we need to stop being paranoid about scaring women, we need to help them make better plans, help them manage their expectations and enable them to make informed decisions before and during their births in order to mitigate some of the mental health impact of births that change direction.

Dr Tonei said: “Unplanned caesareans may have a particularly negative psychological impact on mothers because they are unexpected, usually mentally and physically stressful and associated with a loss of control and unmatched expectations.” So, let’s help women understand caesareans, demystify them, talk about them in positive terms and most importantly help women to plan for their possibility so that, should them become necessary, they are ready and not afraid.

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Birth options after a previous caesarean…

There are a lot of people with a lot of opinions about which way a mother should birth after a previous caesarean. And I am not just referring to medical personnel. It is not uncommon to find men as well as women with strong views on which mode of birth is best – often with little or no medical information to back up their opinion.

It is natural, after a negative birth experience, to be tempted to assume the other birth mode is better, but this may not be the case (unless specific medical indicators suggest otherwise). Where this is the case it is very important we try to ensure our opinions are based in fact not just gut feel.

Unfortunately, with some medical personnel, personal preference will play a part in the advice given and hospital targets are known to impact advice in some facilities. Working out when this is the case is tricky. But unless there are specific medical indicators in the current pregnancy, or a specific outcome in your previous birth which indicates one birth mode over another it is actually far less clear cut than we are led to believe and very much more about our own person view on risks and benefits.

My book dedicates a full appendix (11 pages) to facts and figures about benefits and risks of vaginal and caesarean birth. There are a lot of statistics about medicine’s current understanding of likely outcomes based on numerous international studies. Using this it should be possible to form your own opinion about levels of risk, types of intervention you consider preferrable etc. For example: some women may, on reviewing data view the risks associated with instrumental interventions in a vaginal birth as more risky than a planned caesarean.

Whatever you choose, always remember that in absolute terms the risks of adverse outcomes with either birth mode are incredibly small. Indeed a recent study looking at birth data from over 70,000 births in Scotland between 2002 and 2015 states that:

While “Attempting vaginal birth was associated with an increased risk of the mother having serious birth and post-birth related problems compared to electing for another cesarean section…the absolute risk of complications were small for either type of delivery. Overall, just 1.8% of those attempting a vaginal birth and 0.8% of those having a planned cesarean experienced serious maternal complications.”

Indeed the 2019 NICE Intrapartum Care guideline reports on the review committee’s discussion of the evidence, finding “There was no strong evidence to suggest a difference in outcomes for the baby between a vaginal birth or a repeat caesarean section, and the committee felt that healthcare professionals should inform women about this to aid decisions about mode of birth.”

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Smartphone app. reduces hopsital stay after caesarean

A mobile phone app claims to improve the caesarean birth experience, reducing the average time a woman will stay in hospital after surgery from3.7 to 2.7 days.

The mobile phone app, trialled in the US by Dr Attila Kett at Saint Peter’s University Hospital, New Brunswick, found that using it for a period of weeks before and after surgery reduced the duration of women’s hospital stay. And early results suggest it may also positively impact upon “surgical site infections, urinary tract infections and patient satisfaction”. The study is ongoing.

“The app empowers women by putting them in control of their health care needs,” said Dr. Kett. By offering prompts about appointments, providing pre-surgery information to their palm and prompts about timely medication post operatively it is thought users feel more confident in the process and more likely to monitor their condition effectively.

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Ask questions…

It can be challenging to separate a truth from a half-truth or indeed an out and out lie in some media stories. I’m not talking about fake news here, but simple carelessness or personal bias. But when you think about this challenge in relation to women trying to make decisions regarding their birth, it is more than disconcerting, it is alarming.

Rightly or wrongly, news reports, blogs, TV dramas, each others’ birth stories are all absorbed and digested, feeding our perceptions of what is ‘normal’, what is best for the baby, what is safe and what is not etc.

As I researched my book it became disappointingly apparent that media reports frequently look only as far as the Abstract of a research paper, and then make broadbrush statements that fit their intended message. On reading the papers themselves it is in fact sometimes the case that the reporter has misrepresented or over emphasised the significance of the findings. Yet it is often these media stories, not the research papers, which form the basis of what many women believe to be true and on which we understandably base our own decisions.

Added to this, uptake of antenatal education is only around 60% and significantly lower for women that have already had one baby, (according to a UK Maternity Survey Report by the National Perinatal Epidemiology Unit, 2010). Important information doesn’t always get through, so questioning the truth of what we read elsewhere is important.

Personal bias, political or economic bias can all impact the truth of a report or blog and indeed the advice being given by health practitioners. Really it is only in reading around a subject – going to the original research papers, indeed more than one, that we can start to uncover the detail behind headlines. For example, often a research paper contains caveats – some of which can render a result interesting but very far from conclusive. Yet the media may report the results of that same research paper as beyond a shadow of a doubt – caveats rarely make it into an Abstract.

But a single research paper is a single viewpoint, a single investigation, a single set of conditions and single point in time. It is often possible to find papers that expand upon an idea or indeed completely contradict it – see below – and it is only in reading around, asking questions and questioning the agenda of the author, the researcher or the doctor that we can start to formulate our own position.

This all sounds very scary. How can we know that what we are hearing or reading is reliable. In reality we don’t, but by reading around an issue we stand a greater chance of knowing what questions to ask, it makes us more able to determine what is fact and what is a current best guess, what is a trend and what is plain persona, political or economic bias.

With a background in research I am used to reading research papers and statistics and I will never forget reading a published paper which claimed caesarean section caused obesity in children. It’s good headline fodder and no surprise has been covered time and again in the media. However, in this particular instance, on reading the full paper, I discovered the researchers failed to accommodate several important variables, in particular familial obesity. The presence of such a relevant, confounding variable renders the finding highly questionable. Being unable to rule out the impact of family patterns of behaviour with regards attitudes to food and eating habits makes it impossible to say with any degree of certainty that caesareans cause obesity.

An illustration of how media bandwagons often create more problems…

For quite some time, studies have been talking about the benefits of breastfeeding for babies born by caesarean. Research, suggesting composition of gut bacteria is subtly different according to whether the baby is born vaginally or by caesarean section, this study for example, typically finds caesarean babies breastfed for at least the first 4 weeks will demonstrate broadly similar gut bacteria to babies born vaginally by the time they are 8 weeks old (with implications for immunity systems). In other words, breastfeeding may mitigate the potential impact of a caesarean birth – with regards immunity. Naturally this has fed into the ‘breast is best’ campaign – no bad thing (assuming it is not used to guilt trip mothers about breastfeeding).

But media spin on such studies have on occasion also gone on to suggest – with regards immunity that caesarean born babies are at a significantly disadvantaged adding risks of obesity and asthma to the mix. All of which can understandbaly scare the pants off those women facing an unplanned or unwanted caesarean.

However, in 2017 yet another study, published in Nature Medicine, investigated levels of microbiota found in several locations around baby’s body and found that regardless of age at delivery ALL babies developed very similar levels of microbiota by the time they were 8 weeks old. Indeed by 6 weeks old the microbiota had expanded (and diversified) across ALL infants regardless of their mode of delivery.

The researchers said “We conclude that within the first 6 weeks of life, the infant microbiota undergoes substantial reorganization, which is primarily driven by body site and not by mode of delivery.”

In other words – the link between caesarean delivery and an increase in immune disorders is far from confirmed. Despite this, the media continue to generate emotive headlines, particularly when attempting to regurgitate old myths about the selfishness of women too posh to push, blaming caesareans for all sorts of childhood issues. As you might expect, in line with such scare mongering there has been an increase in the number of women asking about vaginal seeding when told they will need a caesarean delivery as a means of combating their worries about immunity complications. Ironically these women are asking for a procedure far less researched and far less understood than the caesarean itself.

As an aside – please note – the current stance of the UK’s NHS  is “vaginal seeding has unknown risks and is not recommended.”

While in the US ACOG state “At this time, vaginal seeding should not be performed outside the context of an institutional review board-approved research protocol until adequate data regarding the safety and benefit of the process become available.”

Such incomplete articles lead some women to actually consider adding procedures to their birth experience which are in fact far from proven and may actually prove to be harmful to their baby.

It is my intention with this post to draw attention to the challenges women face when trying to make informed decisions. Newspapers print the story that increase readership or reflect the bias of their readership and the onus really has to be on us to conduct our own investigations, asking lots of questions. Most articles name the study or author and with the Internet it is quite easy to get to the source to see what the researchers have actually said.

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Caesarean Birth: A Positive Approach to Preparation and Recovery – A table of contents

For those interested in seeing more detail about the content and structure of my book – the following is the table of contents from the 2nd Edition – available on Amazon and from various other on-line bookstores.

Foreword……………………………………………………………………………… 5

Introduction………………………………………………………………………….. 7

  • 1 Caesareans explained………………………………………….. 11
  • 2 Why prepare for a caesarean birth?………………………….. 19
  • 3 I would prefer a caesarean…………………………………….. 27
  • 4 I do not want a caesarean……………………………………… 37
  • 5 How can I make the most of my caesarean?……………….. 55
  • 6 How can I improve my recovery?…………………………….. 75
  • 7 I am the birth partner, what can I do?……………………… 113
  • A The caesarean procedure……………………………………. 139
  • B Why do caesareans happen?………………………………… 151
  • C The benefits and risks of caesarean and vaginal birth….. 165
  • D Clinical definitions of difficult reactions………………….. 191
  • E Birth guide template………………………………………….. 195
  • F Questions to ask your practitioners………………………… 199

Glossary…………………………………………………………………………….. 203

Other resources…………………………………………………………………… 209

Acknowledgements………………………………………………………………. 217

References…………………………………………………………………………. 221

Index………………………………………………………………………………… 247

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Where can I get advice?

Hospitals remain under pressure to reduce their caesarean rate – despite recommendations to Inspectors to refrain from judging hospitals in this way. And where there are no targets in place, women can still face opposition from individual care givers.

This is why BirthRights – a UK information and advice centre – offer the option for 1:1 advice via their website.

They firmly believe in a woman’s right to an informed choice.

“Women have a right to make choices about the circumstances in which they give birth. This simple but powerful principle was established by the European Court of Human Rights in Ternovszky v Hungary (2010) under the right to private life in Article 8 of the European Convention which encompasses rights to physical autonomy and integrity. Article 8 is a ‘qualified right’ and so limitations on the right are permitted. The Ternovszky case concerned the right to give birth at home, but the principle applies equally to all choices that women make about childbirth. The decision represents a profound challenge to medical authority: if women have a legal right to make a choice, any limitation on that right must be justified. The decision-maker, whether a hospital or a doctor or midwife, must give proportionate reasons for their decision based on the individual circumstances of the woman and their reasons can be tested in court before a judge.”

To ask them a question click here.

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Why Do We Fear a Caesarean Birth?

Australian Birth site, Natural Parent Magazine, recently posted one of my articles. It is great to see more and more birth sites willing to talk about the possibility of a caesarean delivery. Knowledge is power!

“In reality a caesarean is an extraordinary addition to the tools available to those who help us with our births and it should be respected for the advantages if can bring to those who need it.”

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What if I have to have a caearean?

Australian Birth site, BubHub, recently posted one of my articles. It is great to see more and more birth sites willing to talk about the possibility of a caesarean delivery. Knowledge is power.

“With knowledge, a caesarean can be a really powerful experience. One we can remember positively even if it was not the way we thought our birth would pan out…”

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Caesarean targets for hospitals

For years hospitals have been asked to record data about caesarean births. The results of a Freedom of Information request revealed that the way in which this information was recorded varied significantly from one hospital to another.

For example:

  • Inconsistency in criteria used for recording whether a caesarean delivery was emergency or planned
  • Inconsistency in criteria for recording a delivery as a maternal request or performed as a result of an obstetricians recommendation

It is easy to see that in reality reports about current rates face an impossible task – the truth is hard to discern. Despite this many hospitals faithfully report their figures and face judgement for their caesarean rates – some praised for low rates, some criticised for rates that are considered ‘too high’.

In fact the WHO retracted their recommendation for an ideal caesarean rate back in 2009 because there was insufficient evidence to define one.

Despite this, UK hospitals have continued to be scrutinised and judged according to their rates. Loaded statements by official bodies and the press have pushed many hospitals into defining, formally or otherwise, ideal targets for themselves. Stories of women requesting caesareans and being refused are all too common and maternity litigation claims in the UK are now thought to run to billions every year. The personal cost to families of these arbitrary targets can be shown to result in: loss of life, life altering injuries as well as obvious psychological distress.”

Now, finally as the Sunday Times reports “Inspectors have been ordered to stop judging maternity units on their caesarean rates after the care watchdog accepted that it had sent the wrong message on normal birth.”

Heidi Smoult, deputy chief inspector of hospitals – commenting on the report by P Hull which led to this directive – stated that “medical intervention, while important “should never be at the expense of a woman’s or baby’s health.”

The Sundays Times speaking to Alison Wright, of the Royal College of Obstetricians and Gynaecologists, recorded the view that: “The need for a medical intervention can vary dramatically across services and regions, depending on the local demographics and the health needs of women. Therefore, we believe the approach should be more nuanced than promoting a particular maternity indicator, such as a caesarean birth rate.”

A step in the right direction. However, if you are trying to investigate your own birthing options, whether that is to have or avoid a caesarean be aware that internal politics within your hospital may be an additional factor to consider. Despite this new recommendation, it is worth finding out whether your hospital still refers to target levels for caesarean births.

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