Valerie Gommon Midwife’s Blog

Archive for the ‘cascade of intervention’ Category

What is the definition of Natural Childbirth?  A hospital might say that a woman whose labour was induced and who had an epidural was a normal birth; others might say that induction, augmentation, analgesia, episiotomies etc do not constitute a normal birth!

A more radical definition of a natural birth might be a labour that starts spontaneously between 37 and 42 weeks gestation, and progresses to a vaginal birth without any intervention or pharmacological drugs.

Natural childbirth has been given a bad press – women choosing natural childbirth have been described as “hippy types” and indeed there has been an item in the press this week about a midwife who suggested that women would do better to avoid epidurals that has caused considerable outrage!

Pregnancy and childbirth are normal life events, not medical condition; a woman’s body is perfectly designed to give birth.

Of course some pregnancies and labours will need medical help – but the vast majority of women will go through their pregnancy and birth without problems and this process works best when interference is kept to a minimum.

For example anything we do to interfere with this natural processes has consequences – if mother and baby are well I am suggesting that we (the medical profession) should not interfere!

One example of this is the huge number of women whose labours are induced – why?  In some areas women are induced at 41 weeks (interestingly in France a normal pregnancy is defined as 41 weeks!).

Induction is not an easy option.  It is usually quite a lengthy process which makes the mother tired.  It is also usually more painful and the mother is therefore more likely to need pain relief, possibly an epidural … the mother is then less mobile … making it harder for the baby to find a way through the pelvis and consequently she is more likely to need the help of a ventouse or forceps, or even a caesarean section.

We all know that although caesareans are very safe in this country, it is still far safer for both mother and baby if the baby is born vaginally.  A caesarean section is major abdominal surgery which will take weeks and months to fully recover from – and the mother will have a demanding baby to care for too!  Babies born by caesarean also have many more problems, and are far more likely to need to receive Special Care.  There are also implications for future pregnancies – so, although fantastic if needed, caesarean sections are far from ideal.  The World Health Organisation recommends a 5 – 10% caesarean section rate, but our rate is approaching 30%, and I believe 90% at The Portland private maternity hospital!

This interference in birth has been called a “cascade of intervention”, because we do a) we have to do b) and because we do c) d) is also necessary this is also described as “iatrogenic” or hospital induced.  Whatever we do has consequences, for example a woman with an epidural will need more careful monitoring, she will need an IV drip and also a catheter – so you can see this spiral effect, because we do this, we have to do that and so on …

I believe there are several factors that lead to this escalation of intervention in childbirth:

Our cultural conditioning, fear, poor health habits and medical intervention in normal birth (perhaps because of fear of litigation) that make birth difficult often requiring more intervention, including surgery.

With good preparation, much intervention can be avoided – women who have a midwife they know and trust are less likely to need analgesia.  With good preparation they should be in optimal health for the birth – complementary therapies they may have experienced acupuncture, homoepathy, osteopathy or any number of helpful treatments during their pregnancy which will help align their body and prepare them for birth.  They may also have practised relaxation or hypnosis techniques all of which can be hugely beneficial.  There is also much a woman can do to help herself: mobilization, relaxation, support, the use of water …

The satisfaction that a woman feels when she has successfully given birth is amazing – it is empowering and is a fantastic start to the parenting journey, and of course breastfeeding is so much easier when you haven’t got a caesarean section wound on your abdomen.

If things didn’t work out this way for you, remember that you did the very best you could at the time.  Some labours do need help and some mothers and babies wouldn’t survive without the help of our medical colleagues.  If this has raised questions or distress for you I am more than happy to speak to you please do feel free to email me info@3shiresmidwife.co.uk

A difficult or traumatic birth experience has long-lasting implications for both the mother and sometimes her child.  We don’t have many babies in our lifetime and it is important to get things as right as we possibly can!


There has been quite a bit of debate this week about whether women should have access to an epidural in labour.

Of course in the majority of cases women do have access to an epidural in labour if this is what they choose, however many maternity units cannot GUARANTEE that a woman will get an epidural when she requests one.  This may be for several reasons.  A woman who has an epidural needs to have one to one midwifery care to ensure the safety of both the mother and her baby.  If a unit is particularly busy or poorly staffed a midwife may not be available to give this level of care (it is well documented that midwives are often caring for two or more women who are in active labour), secondly, an anaesthetist may not be immediately available.

The debate occurred because there have been several articles in the media recently regarding the National Childbirth Trust’s (NCT’s) views on women’s access to epidurals following the publication of a guidance document, “Making Normal Birth a Reality”, drawn up by the NCT with the backing of the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists. www.appg-maternity.org.uk/resource/Normal+Birth+Consensus+Statement+NEW+LOGO.pdf and www.nct.org.uk/press-office/press-releases/view/128

There was a very interesting debate on Woman’s Hour this week when Belinda Phipps, the Chief Executive of the National Childbirth Trust was interviewed opposite Smriti Singh.  www.bbc.co.uk/radio4/womanshour/02/2009_10_thu.shtml and

The programme highlighted that epidurals are extremely safe (and I say thank goodness for the fantastic medical care we have if it is needed), but I personally do feel that there are very good reasons for avoiding an epidural if possible.

Epidurals are not recommended until a woman is in “established” labour, that is that she is having regular, strong contractions and that her cervix is dilated (usually to 3cm).  The reason for this recommendation is that if the epidural is given earlier the labour could stop as labour may not be fully established.

By having an epidural, a woman is usually confined to bed.  She will need to have her baby continuously monitored by a cardiotocograph machine (CTG) as the epidural can affect the baby, she will also need an intravenous drip because the epidural can significantly lower her blood pressure and she may well also need a urinary catheter to keep her bladder empty.  Being confined to bed will not allow the normal active behaviour of the mother which will help the baby into the optimum position for birth, nor will she have the affect of gravity.  Epidurals occasionally allow the labour to progress more quickly, but more likely the labour will slow and an oxytocic drug (syntocinon) will be needed to increase contractions, and so the “cascade of intervention” continues.  It is also true that women are slightly more likely to need assistance from either a ventouse or forceps to deliver their baby as it is more difficult to “push” out the baby when you have an epidural.

Whilst being an advocate for my clients, and if (given this knowledge) a woman chooses an epidural I honestly believe it is my job to support her in this choice; this said, I believe that far fewer women would actually choose an epidural is they received appropriate one to one support, preferably from a known midwife during their labour.


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